Chinese Medicinal Formulas 7117193735, 9787117193733

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CIP data in Chinese 图书在版编⽬（CIP）数据 ⽅剂学=Chinese medicinal formulas：英⽂/邓中甲，（美）江劭 忞，叶俏波主编. —北京：⼈民卫⽣出版社，2014 国际标准化英⽂版中医教材 ISBN 978-7-117-19373-3 Ⅰ. ①⽅… ①R289

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Website: http://www.pmph.com Book Title: Chinese Medicinal Formulas (International Standard Library of Chinese Medicine) ⽅剂学（国际标准化英⽂版中医教材） Copyright © 2014 by People’s Medical Publishing House. All rights reserved. No part of this publication may be reproduced, stored in a database or retrieval system, or transmitted in any form or by any electronic, mechanical, photocopy, or other recording means, without the prior written permission of the publisher. Contact address: No. 19, Pan Jia Yuan Nan Li, Chaoyang District, Beijing 100021, P.R. China, phone/fax: 8610 5978 7352, E-mail: [email protected] For text and trade sales, as well as review copy enquiries, please contact PMPH at pmphsales@ gmail.com Disclaimer This book is for educational and reference purposes only. In view of the possibility of human error or changes in medical science, the author, editor, publisher and any other party involved in the publication of this work do not guarantee that the information contained herein is in any

respect accurate or complete. The medicinal therapies and treatment techniques presented in this book are provided for the purpose of reference only. If readers wish to attempt any of the techniques or utilize any of the medicinal therapies contained in this book, the publisher assumes no responsibility for any such actions. It is the responsibility of the readers to understand and adhere to local laws and regulations concerning the practice of these techniques and methods. The authors, editors and publishers disclaim all responsibility for any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this book. First published: 2014 ISBN: 978-7-117-19373-3/R·19374 Cataloguing in Publication Data: A catalogue record for this book is available from the CIP-Database China.

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Authors Contributors (Listed alphabetically by name) Chen Jian-ping (陈建萍), Ph.D. TCM Assistant Professor (Honorary Associate Professor), School of Chinese Medicine, The University of Hong Kong, Hong Kong, China Jia Bo (贾波), M.S. TCM Professor, Director of the Formula Department, Chengdu University of TCM, Chengdu, China Li Ji (李冀), Ph.D. TCM Professor, Vice President of Heilongjiang University of TCM, Harbin, China Ruan Shi-bao (阮时宝) Professor, Director of the Formula Department, Fujian University of TCM, Xiamen, China Shen Tao (沈涛), Ph.D. TCM Professor, Vice President of Chengdu University of TCM, Chengdu, China Wang Di (王迪)

Professor, Director of the Formula Department, Changchun University of TCM, Jilin, China Yi Zi-gang (易⾃刚) Professor, Director of the Formula Department, Guangxi College of TCM, Nanning, China Zhou Ran (周然) Professor, President of Shanxi College of TCM, Taiyuan, China Zhou Yong-xue (周永学) Professor, President of Shaanxi College of TCM, Xi’an, China Translators (Listed alphabetically by name) Azure (Duan Ying-zhe) (段颖哲), Ph.D., L.Ac., TCM Harmony Acupuncture & TCM, Atlanta, GA, U. S. A. Hu Peng (胡鹏), Ph.D. TCM Lecturer of Chinese Medical Formulas, Chengdu University of TCM, Chengdu, China Jin Zhao (⾦钊), Ph.D. TCM Attending Physician, Lecturer, Chengdu University of TCM, Chengdu, China Li Yi-bei (李⼀北), Ph.D. Candidate TCM Attending Physician, Lecturer, Department of Endocrinology, Affiliated Hospital of Chengdu University of TCM, Chengdu, China Ma Xi-tao (马喜桃), M.S. TCM Interpreter/Translator, Attending Physician,

Affiliated Hospital of Chengdu University of TCM, Chengdu, China Song Yao-ping (宋姚萍), Ph.D. L.Ac., TCM The Academy of Oriental Medicine at Austin, Austin, TX, U. S. A. Wang Jing (王静), Ph.D. TCM Attending Physician, Lecturer, Clinical College, Chengdu University of TCM, Chengdu, China Wu Shi-guo (吴施国), Ph.D. TCM Physician, Associate Professor, Yunnan College of TCM, Kunming, China English Editors Greg Zimmerman, M.S., L.Ac. Acupuncturist, Yi An Chinese Medicine Clinic, Irvine, CA, USA Lara Deasy, Bsc (Hons) TCM, B.M. (Beijing) TCM, MRCHM

About the Authors

Deng Zhong-jia（邓中甲） Deng Zhong-jia, State Council Expert for Special Allowance, is a professor and doctoral supervisor of Chengdu University of TCM. He is the principal academic leader of the state-level formulas courses, teaching team and key disciplines of the State Administration of TCM of China. Prof. Deng was the Deputy Committee Director of the Branch Association of Formulas, China TCM Association (June 2002). The two textbooks: Formulas of Traditional Chinese Medicine, he edited in 2001 and 2008, are widely used in China. He was awarded the Excellent Textbook Prize for his contribution to textbook editing in 2009.

Greg Zimmerman Greg Zimmerman is a Licensed Acupuncturist and Chinese Medicine Practitioner located in Southern California. He has been involved in the academics of traditional Chinese medicine since 1996 serving as a lecturer, consultant and editor for prominent Chinese herbal manufacturing companies, educational organizations, and TCM colleges. Greg Zimmerman has maintained a private practice, the Yi An Chinese Medicine Clinic (奕安中醫診所), located in Irvine, CA since 1997. For the past 15 years, he has taught a variety of classes on various subjects of traditional Chinese medicine with an emphasis on Chinese herbal formulas and medicinals.

Ye Qiao-bo（叶俏波） Ye Qiao-bo is a graduate of the Chengdu University of TCM (Bachelor in Chinese Herbal Medicine, 2001; Master in Formulas, 2004; Ph.D in Formulas, 2009). She worked as an editorial member and translator for the Encyclopedia of Medicinal Plants at the School of Chinese Medicine, Hong Kong Baptist University, Kowloon Tong (Research Assistant, June 2004). Currently, she teaches formulas in the Chengdu University of TCM and serves as a physician in the affiliated clinic of the university.

Editorial Board for International Standard Library of Chinese Medicine Executive Directors Li Zhen-ji (李振吉) Vice Chairman and Secretary-general, World Federation of Chinese Medical Societies, Beijing, China Hu Guo-chen (胡国臣) President and Editor-in-Chief, People’s Medical Publishing House, Beijing, China Directors You Zhao-ling (尤昭玲) Former President and Professor of Chinese Medical Gynecology, Hunan University of TCM, Changsha, China Xie Jian-qun (谢建群) President and Professor of Chinese Internal Medicine, Shanghai University of TCM, Shanghai, China General Coordinator

Liu Shui (刘⽔) Director of International TCM Publications, People’s Medical Publishing House, Beijing, China Members (Listed alphabetically by last name) Chang Zhang-fu (常章富) Professor of Chinese Materia Medica, Beijing University of CM, Beijing, China Chen Hong-feng (陈红风), Ph.D. TCM Professor of Chinese External Medicine, Shanghai University of TCM, Shanghai, China Chen Jia-xu (陈家旭), Ph.D. TCM Professor of TCM Diagnostics, Beijing University of CM, Beijing, China Chen Ming (陈明), Ph.D. TCM Professor of Shāng Hán Lùn, Beijing University of CM, Beijing, China Cui Hai (崔海), Ph.D. TCM Associate Professor of TCM, Capital Medical University, Beijing, China Deng Zhong-jia (邓中甲) Professor of Chinese Medicinal Formula, Chengdu University of TCM, Chengdu, China Ding Xiao-hong (丁晓红)

Associate Professor of Tui Na, International Education College, Nanjing University of TCM, Nanjing,China Douglas Eisenstark, L.Ac. Professor of Chinese Medicine, Emperor’s College, Los Angeles, USA Stephen X. Guo (郭鑫太), M.A. International Affairs Director of Jande International, New York, USA Han Chou-ping (韩丑萍) Associate Professor, International Education College, Shanghai University of TCM, Shanghai, China Hu Jun (胡俊), B.A. Medical English Currently Pursuing Master’s of Science in Social History of Medicine, Peking University, Beijing, China Hu Ke-xin (胡克信), Ph.D. TCM Professor of Otorhinolaryngology, Keelung City Municipal Hospital, Taiwan, China Hu Zhen (胡臻) Professor and Head of Department of Traditional Chinese Medicine, Wenzhou Medical College, Wenzhou, China Huang Fei-li (黄霏莉) Professor of Cosmetology, Hong Kong Baptist University, Hong Kong, China Russell William James, M.S. TCM IELTS Examiner & Marker, Beijing, China

Jia De-xian (贾德贤), Ph.D. TCM Professor of Chinese Materia Medica, Beijing University of CM, Beijing, China Jin Hong-zhu (⾦宏柱) Professor of Acupuncture & Tui Na, Nanjing University of TCM, Nanjing, China Lixing Lao (劳⼒⾏), Ph.D. MB, L.Ac. Professor and Director, School of Chinese Medicine, The University of Hong Kong, Hong Kong, China Adjunct Professor, Center for Integrative Medicine, University of Maryland, Baltimore, Maryland, USA Past Co-President of the Society for Acupuncture Research Vice President, World Federation of Acupuncture-Moxibustion Societies (WFAS) Hon K. Lee (李汉光), Dipl. OM, L.Ac. Director of the Jow Ga Shaolin Institute, Herndon, Virginia, USA Li Dao-fang (李道坊), Ph.D. TCM President of Florida Acupuncture Association; Executive Board Director, National Federation of Chinese TCM Organizations, Kissimmee, USA Mei Li (李梅), M.S. TOM, L.Ac.

Translator and Editor, People’s Medical Publishing House, Beijing, China Li Ming-dong (李名栋), Ph.D. OMD, L.Ac. Professor of Chinese Internal Medicine, Yo San University of Traditional Chinese Medicine, Los Angeles, USA Li Wan-ling (李云宁) Qi Gong and TCM Translator, Beijing, China Liang Li-na (梁丽娜), Ph.D. TCM Associate Professor of Ophthalmology, Eye Hospital of China Academy of Chinese Medical Sciences, Beijing, China Liu Zhan-wen (刘占⽂) Professor of Chinese Medicine, Beijing University of CM, Beijing, China Lü Ming (吕明) Professor of Tui Na, Changchun University of CM, Changchun, China Mark L. Mondot, B.A. Chinese Language, L.Ac. Translator and Editor, People’s Medical Publishing House, Beijing, China Jane Lyttleton, Hons, M Phil, Dip TCM, Cert Ac. Lecturer, University of Western Sydney, Sydney, Australia Julie Mulin Qiao-Wong (乔⽊林) Professor of Chinese Medicine, Victoria University, Melbourne, Australia

Andy Rosenfarb, M.S. TOM, L.Ac. Acupuncture Health Associates, New Jersey, USA Paul F. Ryan, M.S. Dipl.OM, L.Ac. (NY, CA, China) Acupuncture Preceptor, Lutheran Medical Center, Department of Neurology, Brooklyn, New York, USA Martin Schweizer, Ph.D. Molecular Biology, L.Ac. Emeritus Professor of Medicinal Chemistry, University of Utah, USA Secondo Scarsella, MD, DDS Visiting Professor of Tui Na, Nanjing University of TCM, China Department of Maxillofacial Surgery, San Salvatore Hospital, L'Aquila, Italy Sun Guang-ren (孙广仁), M.S.TCM Professor of TCM Fundamentals, Shandong University of TCM, Jinan, China Tsai Chun-hui, Ph.D. Associate Professor of Pediatrics, School of Medicine, University of Colorado, Denver, USA Tu Ya (图娅) Professor of Acupuncture and Moxibustion, Beijing University of CM, Beijing, China Wang Shou-chuan (汪受传) Professor of TCM Pediatrics, Nanjing University of TCM, Nanjing, China

Wei Qi-ping (韦企平) Professor of Ophthalmology, Beijing University of CM, Beijing Douglas Wile, Ph.D. Former Professor of History & Philosophy of Chinese Medicine and of Chinese Language at Pacific College of Oriental Medicine, New York Professor of Chinese Language at Alverno College, Milwaukee, USA Jane Frances Wilson, M.S., L.Ac. Senior Lecturer of School of Life Sciences, University of Westminster, London, UK Xiao Ping (肖平) Associate Professor, Hunan University of TCM, Changsha, China Xu Shi-zu (徐⼠祖), M.A. Chinese Martial Arts Chinese Traditional Sports and Health Cultivation Instructor, School of Physical Education in Wenzhou Medical College, Wenzhou, China Yan Dao-nan (严道南) Professor of Otorhinolaryngology, Nanjing University of TCM, Nanjing, China Ye Qiao-bo (叶俏波), Ph.D. TCM Physician, Lecturer of Chinese Medicinal Formulas, Chengdu University of TCM, Chengdu, China Zhang Ji (张吉) Professor of Acupuncture and Moxibustion, Beijing University of CM, Beijing, China

Zhang Ji (张季), Ph.D. TCM Professor of Chinese Materia Medica, Emperor’s College of Oriental Medicine, Alhambra University, Dongguk University, Los Angeles, USA Helen Q. Zhang (张齐), Ph.D. TCM, L.Ac. Director of Qi TCM Clinic, New York, USA Zhang Qing-rong (张庆荣) Professor of TCM Fundamentals, Liaoning University of TCM, Shenyang, China Zhao Bai-xiao (赵百孝), Ph.D. TCM Professor of Acupuncture and Moxibustion, Dean, School of Acupuncture and Moxibustion, Beijing University of CM, China Zhao Xia (赵霞), Ph.D. TCM Professor of TCM Pediatrics, Nanjing University of TCM, Nanjing, China Zhou Gang (周刚), Ph.D. TCM Lecturer of Shāng Hán Lùn, Beijing University of CM, Beijing, China Greg Zimmerman, M.S., L.Ac. Acupuncturist, Yi An Chinese Medicine Clinic, Irvine, CA, USA Sponsored by World Federation of Chinese Medical Societies

Preface The science of formulas is a subject dealing with the treatment and theories of formulas, as well as the clinical application. It is an important basic course in TCM and should be studied after the Fundamentals of TCM, Diagnostics of TCM and Chinese Materia Medica courses. The textbook is divided into two parts. The first part is General Discussion, focusing on the Historic Overview of Chinese Medicinal Formulas, Treatment Methods and Formulas, Classification of Formulas, Composition of Formulas, Types of Formula Preparation and Administration Methods. The second part includes specific discussions on formulas in 18 categories. It contains more than 360 principal formulas and associated formulas, which are divided into fundamental formulas, representative formulas and commonly used formulas. Each chapter contains four parts: Brief Introduction, Specific Formulas, Summary and Questions. The Brief Introduction includes the definition of each type of formula, treatment method, function, application, cautions, clinical features, compatibility methods and the name of commonly used formulas. Specific Formulas includes the Source Text, Formula Ingredients, Preparation and Administration, Formula Indications, Analysis of Fundamental Pattern Pathogenesis, Formula Analysis, Formula Actions, Unique Combination Features, Further Clarification, Formula Applications, Associated Formulas, Case Studies, and Comments. The

Summary is a brief comparison between the formulas. The Questions try to develop the ability of independent thinking and comprehensive analysis based on the important contents of each chapter. This textbook is characterized by the following features: 1.Using clear and easily understood forms to elucidate Formula Analysis, Modifications, and Comparisons & Contrasts. 2.The item of Further Clarification is set to elucidate the difficulties and doubts. 3.The fundamental combinations are concluded in the Formula Analysis form. Also, the Unique Combination Features helps readers to learn more compatibility skills. 4.One to four typical and practical cases by famous ancient or current TCM practitioners are listed in most formulas. It can help readers master the core pathomechanism and learn how to modify the formulas in different specific cases. Work Assignment: The General Introduction was written by Deng Zhong-jia. Chapter 1 and Chapter 3 were written by Jia Bo. Chapter 2, Chapter 12 and Chapter 18 were written by Yi Zi-gang. Chapter 4 was written by Zhou Yong-xue. Chapter 5 and Chapter 6 were written by Shen Tao. Chapter 8 and Chapter 10 were written by Wang Di. Chapter 11 and Chapter 13 were written by Ruan Shi-bao. Chapter 14 was written by Li Ji. Chapter 7 and Chapter 16 were written by Zhou Ran. Chapter 9, Chapter 15 and Chapter 17 were written by Chen Jian-ping. This book can be used as an authentic textbook for overseas students. Moreover, it can serve as reference for TCM practitioners with its practical

content. Contributors May, 2014

Table of Contents

Part One General Discussion CHAPTER 1 Historic Overview of Chinese Medicinal Formulas CHAPTER 2 Treatment Methods and Formulas CHAPTER 3 Classification of Formulas CHAPTER 4 Composition of Formulas CHAPTER 5 Types of Formula Preparation CHAPTER 6 Administration Methods Part Two Formula Monographs CHAPTER 1 Exterior-Releasing Formulas CHAPTER 2 Downward-Draining Formulas CHAPTER 3 Formulas that Harmonize CHAPTER 4 Heat-Clearing Formulas CHAPTER 5 Formulas that Warm the Interior CHAPTER 6 Supplementing and Boosting Formulas CHAPTER 7 Astringent Formulas CHAPTER 8 Orifices-Opening Formulas CHAPTER 9 Mind-Calming Formulas CHAPTER 10 Qi-Rectifying Formulas CHAPTER 11 Blood-Regulating Formulas CHAPTER 12 Wind-Expelling Formulas CHAPTER 13 Dryness-Relieving Formulas CHAPTER 14 Dampness-Dispelling Formulas CHAPTER 15 Phlegm-Dispelling Formulas CHAPTER 16 Digestion-Promoting Formulas CHAPTER 17 Worm-Expelling Formulas CHAPTER 18 Emetic Formulas Appendix: List of Medicinals Index by Chinese Formulas-Pin Yin Names Index by Symptoms and Diseases

Index by Classical Texts

Part One General Discussion CHAPTER 1 Historic Overview of Chinese Medicinal Formulas The history of traditional Chinese medicinal formulas can be traced back two thousand years to its formation. According to Consolidated National List of Books in Traditional Chinese Medicine (Quán Guó Zhōng Yī Tú Shū Lián Hé Mù Lù, 全国中医图书联合⽬录), there are more than one thousand nine hundred fifty categories of formula books available today stemming from the Jin and Tang Dynasty (265~907). The number of medical works relevant to Chinese formulas is even greater. The consistent, continuous publications of those books throughout history reflect the development of traditional Chinese formulation methods. As “one who discusses the past we can definitely relate to the present”[1] says there is a realistic meaning to learning this constructive subject of traditional Chinese medicine. In order to effectively grasp its future trend, one needs to understand its overall history of development and be familiar with the characteristics and values of classic formula studies.

I. Pre-Qin Period (2000~221 BCE)

During the long history of human development, our ancestors gradually accumulated medicinal knowledge through trial and practice. They passed their experience from one generation to the next generation. Naturally, they were involved in experimenting with the use of certain medicinal combinations. A good example of an early combination and application recorded in Commentary of Zuo (Zuŏ Zhuàn, 左传) is jū xiōng (chuān xiōng) and mài qū used together to treat abdominal sickness due to freshwater fish. Rites of Zhou (Zhōu Lĭ, 周礼) contains records of “combined medicinals” and “combined fix (qí, 齐)”. In Records of the Grand Historian (Shĭ Jì, 史记), it stated that Doctor Bian Que treated the Prince of the Guo State for sudden syncope with the “Fix of Eight Minus”. The term “fix”, also known as “formula (jì, 剂)” in later eras, refers to the practice of combining, mixing, and matching different medicinal materials. Early on, formulas were fairly simple with only a few medicinals. By combining two or more medicinals in certain ways to make formula combinations, the treatment efficacy improved and unwanted adverse reactions and toxic effects were reduced. It was a great advancement in the developmental process of Chinese medicine from using simple medicinals to using formulas. In 1977, one hundred thirty broken pieces of Han Dynasty documentary bamboo strips of the book named Thousands of Creatures (Wàn Wù, 万物) were found in Fuyang of Anhui Province. It had been recorded that shāng lù combined with lamb head was used to treat tympanites and lĭ shí (bái fán) combined with shān zhū yú were used for overexertion. This is so far the earliest documented archeological discovery regarding Chinese formulas. Although it cannot be determined exactly when Chinese formulas were initially formed, it can be determined that

multi-medicinal formulas were invented no later than the Spring and Autumn Period (770~476 BCE) or the Warring States Era (475~221 BCE). A series of silk books as well as bamboo and wooden literature strips were discovered in the Han Dynasty Tomb III of Ma-wang-dui, Changsha, Hunan Province in 1973. Formulas for Fiftytwo Diseases (Wŭ Shí Èr Bìng Fāng, 五⼗⼆病⽅), Health Maintenance Formulas (Yăng Shēng Fāng, 养 ⽣⽅), Miscellaneous Treatment Formulas (Zá Liáo Fāng, 杂疗⽅) and Miscellaneous Forbidden Formulas (Zá Jìn Fāng, 杂禁⽅) were among the formula books. The Formulas for Fifty two Diseases was found in fair condition having a large volume and rich content. The book was completed, without a title, at the end of the Warring States Period. It was the people who reorganized the artifact who named it, based on the fifty-two topics classified in its contents. It is the most ancient formula book known to date. There are two hundred eighty-three medicinal formulas in the book that cover one hundred illnesses from multiple clinical areas. A total of two hundred forty two medicinals were used in the formulas. Quite a few of them were not recorded in Shen Nong’s Classic of the Materia Medica (Shén Nóng Bĕn Căo Jīng, 神农本草经) (a.k.a. Classic of Materia Medica). Administration methods for both internal and external use were recorded in the book. Pills, decoctions, beverages, and powders are described among the formulas for internal use. All of the preparation procedures, except for the pill, were without names for the different types. External preparations included patches, bathing, steaming, hot compresses, and so forth. In addition, there were a number of requirements and guidelines regarding the preparations and dosages.

II. Western Han (206 BCE~9 AD) and Eastern Han (9~220 AD) Dynasty Clinical application of formulas became popular during the Han Dynasty. Chun Yu-yi of the early Han mentioned four formulas, including “Decoction of Fire,” in his book Diagnostic Collections (Zhěn Jí,诊籍). Unfortunately, the medicinals cannot be determined since it was such a long time ago. According to the historic records, the number of formula books was enormous with “eleven classic formula schools”consisting of two hundred seventy-four volumes recorded in History of the Former Han Dynasty-Annals for Arts and Literature (Hàn Shū-Yì Wén Zhì, 汉书·艺⽂ 志) alone. Unfortunately, they have now all scattered and disappeared. On the other hand, Formulas for Treating a Hundred Diseases (Zhì Băi Bìng Fāng, 治百病⽅), unearthed in 1972 at Han-tan-po in Wuwei City of Gansu Province, had thirty-six formulas recorded on wooden strips. It described more than one hundred types of medicinal materials in the various forms of decoctions, pills, pastes, powders, and tinctures. The formulas treat diseases of internal medicine, external medicine, gynecology, ophthalmology, and otorhinolaryngology. This discovery showed that formula use had reached a fairly high level by that time. Formulas were refined by clinical practice to improve their curative effects and reduce toxicity and side effects of medicinals via widely used combinations. This phenomenon alleviated the common fear people had towards medicinal treatment. By the end of the Western Han Dynasty, the appellation of medicinals changed from “poisonous drugs (毒药)” to “materia medica (本草)”, reflecting the important progress made in

promoting both formulas and medicinals in the early development stages of Chinese medicine. In the Eastern Han period, the theories of Chinese formulation advanced at a greater pace. This is reflected in the Seven Grand Discussions of The Yellow Emperor’s Inner Classic (Huáng Dì Nèi Jīng, 黄帝内经), which was mostly written after the establishment of the Eastern Han Dynasty. The Yellow Emperor’s Inner Classic contributed to Chinese formulation theory in three main ways. First of all, it summarized treatment principles and methods comprehensively and systematically for the first time. It included important axioms such as “carefully regulate yin and yang to reach the expected balance,”[2] “find the root cause while treating a disease,”[3] and “treat a disease according to its pertaining organ.”[4] It also described the holistic approach, treatment based on urgency, moderation between root and branch, and treatment according to the three factors (climate, locality, and individual). Furthermore, the treatment methods provide guidelines to establish detailed practical methods and compose appropriate formulas. Second, it brought forward the fundamental structural requirements and theory of “chief, deputy, assistant and envoy” used to compose a formula. It also established the overall scope and meaning of the four medicinal materials. It says that “[one that] manages the main disease is the chief, [one that] supports the chief is the deputy, and [one that] assisting the deputy is the envoy.”[5] Third, although the book was specifically explaining the fundamental theories of Chinese medicine, it had thirteen formulas recorded including Shēng Tiĕ Luò Yĭn (Iron Flakes Beverage), Sì Wū Zéi Gŭ Yī Lú Rú Wán (Four Cuttlebone and One Indian Madder Root Pill), Zuŏ Jiăo Fà Jiŭ (Left

Head Hair Wine), Lán Căo Tāng (Boatorchids Decoction), and Bàn Xià Shú Mĭ Tāng (Pinellia and Husked Sorghum Decoction). While there were not many formulas in this book, there were a variety of formula types and diverse administration methods. The details of the medicinal processing, formula preparations, and applications of these formulas were emphasized. Therefore, they have come to be respectfully referred to as “classic formulas” by later generations. Towards the end of the Eastern Han Dynasty, Zhang Zhong-jing completed the Treatise on Cold Damage and Miscellaneous Diseases (Shāng Hán Zá Bìng Lùn, 伤寒杂病论) in an effort to save lives during a massive epidemic breakout of infectious disease. He “diligently sought out the ancient precepts and collected a wide range of formulas.”[6] The theoretic foundation of the Treatise on Cold Damage and Miscellaneous Diseases is based on The Yellow Emperor’s Inner Classic and it integrates knowledge from the Classic of Materia Medica and the Classic of Decoction Fluids (Tāng Yèi Jīng, 汤液经) in combination with his unique clinical experience. This combination integrates and unites various theories, methods, formulas, and medicinals into one masterpiece that represents the pinnacle of the Eastern Han’s medical capabilities. It also established a solid foundation of pattern differentiation in Chinese medical science. The book was reorganized by Wang Shu-he of the Jin Dynasty (265~420 AD) and Lin Yi of the Song Dynasty (960~1127 AD). It then reappeared as two books, Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) and Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略), which had broad circulation. From what we can see today, Treatise on Cold Damage contains one hundred thirteen formulas, and the Essentials from the Golden Cabinet contains two hundred forty-five formulas. Without double counting, the

total is three hundred twenty-three formulas. Most of them are based on specific theories and methods with rigid rules of composition and medicinal selection. There are typically just a few medicinals in these formulas with clearly distinguished priorities and carefully crafted modifications. It thereby gained admiration from Chinese medical professionals of the past and present both in China and worldwide. Many of them are foundational formulas still prescribed today. Some examples are Má Huáng Tāng (Ephedra Decoction), Má Xìng Shí Gān Tāng (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction), Sì Nì Tāng (Frigid Extremities Decoction), Yīn Chén Hāo Tāng (Virgate Wormwood Decoction), Guì Zhī Tāng (Cinnamon Twig Decoction), Xiăo Chái Hú Tāng (Minor Bupleurum Decoction), Wŭ Líng Săn (Five Substances Powder with Poria), Zhēn Wŭ Tāng (True Warrior Decoction), Dà Chéng Qì Tāng (Major Purgative Decoction), Bái Hŭ Tāng (White Tiger Decoction), and Shèn Qì Wán (Kidney Qi Pill). Many famous formulas throughout history are either modifications from these formulas or they follow the combination rules, theories, and methods set by Zhang Zhong-jing. Therefore, Treatise on Cold Damage and Miscellaneous Diseases has been canonized as the “ancestor of all formula books”.[7]

III. The Period of Wei (220~265 AD), Jin (265~420 AD), and Southern and Northern Dynasties (420~589 AD) China was divided. The states succeeded one another, and they often were either confronting each other or in war during this period of time. Since society was unstable, the production, transportation, and trade of materia medica were severely disrupted. Due to circumstance, the clinical formulas of the time emphasized practicality over theoretic discussion. This promoted simple compositions with fast effectiveness. In the three hundred plus years, there were a large number of formula books written. However, most of them vanished with history. Currently, there are only three books preserved relatively well that have great impact, Emergency Formulas to Keep Up One’s Sleeve (Zhŏu Hòu Bèi Jí Fāng, 肘后备急⽅), Light Taste of Classic Formulas (Xiăo Pĭn Fāng, ⼩品⽅), and Liu Juan-zi’s GhostBequeathed Formulas (Liú Juān Zĭ Guĭ Yí Fāng, 刘涓⼦鬼遗⽅). Emergency Formulas to Keep in One’s Sleeve (Zhŏu Hòu Bèi Jí Fāng, 肘后备急⽅) (a.k.a. Life-Saving Formulas to Keep in One’s Sleeve) was written by Ge Hong, a famous medical scholar in Eastern Jin Dynasty (317~420 AD). He had a great deal of knowledge and wrote a lot of books, but most of his medical books have been lost. Life-Saving Formulas to Keep in One’s Sleeve (Zhŏu Hòu Bèi Jí Fāng, 肘后备急⽅) was extracted from three of the one hundred volumes of Medicinal Formulas from the Golden Cabinet (Jīn Guì Yào Fāng, ⾦匮药⽅). It was actually designed to be easy to carry and reference. This is how the name Keep in One’s Sleeve was derived. Tao Hong-jing then expanded the book and changed the title to

Hua-yang Yin-ju’s 101 Supplemented Formulas to Keep in One’s Sleeve (Huá Yáng Yĭn Jū Bŭ Quē Zhŏu Hòu Băi Yī Fāng, 华阳隐居补阙肘后百⼀ ⽅). Later, Yang Yong-dao of the Jin State (1115~1234 AD) attached partial formulas from Materia Medica Arranged According to Pattern (Zhèng Lèi Bĕn Căo, 证类本草) to the book and named it Formulas to Keep in One’s Sleeve with Associated Extensions (Fù Guăng Zhŏu Hòu Fāng, 附广肘后 ⽅). It became the archetype of all versions published from the Ming (1368~1644) and Qing Dynasty (1636~1912 AD) forward. While selecting these formulas, Doctor Ge worked hard to include “single medicinal ingredient [formulas] that were easy to get. [Some were] simple but effective. Looking around fences and roadsides, one could find medicinal materials everywhere. Ailments that the general public would be concerned about were thoroughly explained. With a copy at home, people may not even need a doctor.”[8] For the purpose of “saving lives”, the majority of the formulas were applicable in emergencies such as stroke, syncope, drowning, external injury, and poisoning. The total of five hundred ten single medicinal and four hundred ninety-four multiple medicinal formulas, together with their administration methods were “all tested and recorded” by Doctor Ge himself and written in simple and concise language. For example, getting the juice out of a handful of fresh qīng hāo to treat malaria provided precious insight for the modern research and development of artemisinin. The first record of formulas such as Cōng Chĭ Tāng (Scallion and Fermented Soybean Decoction) and Huáng Lián Jiĕ Dú Tāng (Coptis Toxin-Resolving Decoction) were in this book. Simplicity, convenience, affordability, and effectiveness are the distinctive characteristics of Life-Saving Formulas to Keep in One’s Sleeve (Zhŏu Hòu Bèi Jí Fāng, 肘后备急⽅).

Light Taste of Classic Formulas (Xiăo Pĭn Fāng, ⼩品⽅) by Chen Yan-zhi systematically organized empirical formulas after the Treatise on Cold Damage and Miscellaneous Diseases was written. Both were equally reputable during the Sui (581~618 AD) and Tang Dynasty (618~907 AD). The original work was lost during war and turmoil sometime between the end of the Tang and the beginning of the Song Dynasty (960~1279 AD). However, many materia medica and formula books excerpted its literature. In 1985, a scattered volume of the book was discovered in Japan. Mr. Tang Wan-chun, of the modern era, collected more than eight hundred eighty pieces of the missing scripts from a wide range of Chinese and foreign documentations, added more than seven hundred seventy explanatory statements, and published it as Editorial Collection of Light Taste of Formulas with Commentary (Xiăo Pĭn Fāng Jí Lù Jiān Zhù, ⼩品⽅辑录笺 注) in 1990. The content covers various clinical departments with discussions of theories, methods, formulas, and medicinals. It mainly contains simple, convenient, affordable, and effective formulas. Dr. Chen was very clear that “cold damage and epidemic warm diseases were the result of unusual [pathogenic] qi,”[9] and that the formulas and medicinals should be different due to different etiologic causes. Cold damage was often treated with má huáng and guì zhī for their pungency and warmth. Epidemic warm diseases were treated with gé gēn, dà qīng yè, bái wēi, huáng lián, and huáng qín for their acrid-cool, heat-clearing, and toxinresolving properties. Sháo Yào Dì Huáng Tāng (Peony and Rehmannia Decoction, 芍药地黄汤), later named Xī Jiăo Dì Huáng Tāng (Rhinoceros Horn and Rehmannia Decoction, 犀角地黄汤), was used to treat patients affected by “cold damage or warm disease [with] internal blood stasis and amassment.”[10] It sets groundbreaking ideas by applying toxin-resolving, blood-cooling, and stasis-dissolving methods while treating warm diseases.

Liu Juan-zi’s Ghost-Bequeathed Formulas (Liú Juān Zĭ Guĭ Yí Fāng, 刘涓⼦鬼遗⽅) was originally composed by Liu Juan-zi of the Jin Dynasty (265~420 AD) and later rearranged by Gong Qing-xuan of Southern Qi State (479~502 AD). The book was a collection of external formulas and a discourse regarding incised wounds, abscesses, scabies, tinea, burns, and so on. As the earliest existent specialty book in Chinese external medicine, it represents the achievement of the Wei, Jin and Northern and Southern Dynasties.

IV. Sui (581~618 AD) and Tang (618~906 AD) Dynasties The social economy improved and stabilized during these two dynasties. Chinese medicinal formulas achieved great developmental progress owing to closer relationships among different ethnic groups, broad exchange with foreign countries, and attention to the medical profession by the Tang imperial government. Besides participating in or organizing the compilation of formula books, the royal court once ordered prefectures and counties to write Formulas for Vast Relief (Guăng Jì Fāng,广济⽅) on big boards and install them by major roads across the countryside for pedestrians to use in case of emergency. All of these actions promoted the compilation of formula literature as well as to popularize it. In this period, numerous formula books, some with huge volumes, appeared one after another. It was a phenomenon that never happened before. According to Book of Sui-Annals for Classic Books (Suí Shū-Jīng Jí Zhì, 隋书·经籍志), there were two hundred fifty-six types of formula books and a total of four thousand five hundred ten volumes. Classified Formulas of The Four Seas (Sì Hăi Lèi Jù Fāng, 四海类聚⽅) was one of them that had two thousand six hundred volumes. An undercounted statistic in Considering Pre-Song Medical Works (Sòng Yĭ Qián Yī Jí Kăo, 宋以前医 籍考) says that there were hundred thirty-eight empirical formula books at the time in addition to Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng, 备急千⾦要⽅), Supplement to ‘Important Formulas Worth a Thousand Gold Pieces’ (Qiān Jīn Yì Fāng, 千⾦翼⽅) and Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘要). The people of the Tang era also liked to collect foreign and

minority formulas as well as to compose formulas using foreign medicinals. Some examples are Chī Lì Jiā Wán (Atractylodes Macrocephalae Pill), Qí Pó Wán (Jivaka Pill), Ā Jiā Tuó Wán (Agada Pill), Mán Yí Jiŭ (Bbarbarian Wine), and Xiōng Nú Lù Sù Wán (Hun’s Camping Pill). All of these are evidence that Chinese medicinal formulas absorbed the fortes from the medical practices of other ethnic groups. Despite the tremendous amount, most of the Sui and Tang formula books were lost. The existing works that represent the true quality of Chinese formulas of the Tang Dynasty are Important Formulas Worth A Thousand Gold Pieces for Emergency (shortened name: Important Formulas Worth a Thousand Gold Pieces) (Bèi Jí Qiān Jīn Yào Fāng, 备急 千⾦要⽅), Supplement to ‘Important Formulas Worth a Thousand Gold Pieces’ (Qiān Jīn Yì Fāng, 千⾦翼⽅) and Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘要). Both of the outstanding “A Thousand Gold Pieces” books were written by Sun Si-miao, who was a great physician and medicinal expert in the Tang Dynasty. Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng, 备急千⾦要⽅) had thirty volumes, one hundred thirty-two categories and five thousand three hundred or more formulas. Supplement to ‘Important Formulas Worth a Thousand Gold Pieces’ (Qiān Jīn Yì Fāng, 千⾦翼⽅) also had thirty volumes with more than two thousand two hundred formulas, which was a great addition to the first book. Although they were labeled as formula books, they were, in fact, comprehensive magnum opuses of Chinese medicine. If we look at the formula sections of the first book, it contains not only classic literature and ancient formulas, but also single medicinal folk formulas. It summarized previous experiences and added innovative ideas.

The book classified formulas based on disease types, and the subclassification was based on viscera and bowels, which had a huge impact on zang-fu pattern differentiation. The arrangement of the categories was prioritized, so that the first three volumes were “formulas for women” followed by one volume of “formulas for children and infants”. This reflects the author’s particular concern regarding disease prevention and treatment for women and children. The formulas used to treat infertility of men and women were different, which was very insightful. Regarding warm diseases, Dr. Sun emphasized the use of heat-clearing and toxin-resolving medicinals. He would use xī jiăo, dì huáng, cè băi yè, pú huáng, huáng qín, ē jiāo, and dà huáng for hemorrhage; léi wán, wú yí, xiān hè căo, and guàn zhòng to expel intestinal parasites; and gŏu qĭ zĭ, tiān huā fĕn, mài dōng, zhī mŭ, huáng qí, rén shēn, and rén rŭ for xiāo kĕ (wasting-thirst,消渴). Even by current standards, the selection of medicinals was very accurate. Deficiencysupplementing medicinals were often mixed with mutton, venison, beef marrow, rabbit liver, lamb liver, pork stomach, walnut, buckwheat, and sesame oil for the treatment of deficiency patterns. A volume designated for “food therapy” emphasized that “[he who would] use food to relieve illness, emotional disturbance, or indisposition could be called a great [medical] practitioner”[11]. This volume is credited for providing early experience of food therapy and medicinal meals as a reference to the readers, so that the knowledge could be carried forward. The book also recorded formulas for health maintenance and cosmetology, leaving precious experience for future generations regarding deficiency supplementation, anti-aging, wellness, and fitness. Last but not least, many formulas were profoundly influential and are still widely used in the medical field, including Wēn Dăn Tāng (Gallbladder-Warming Decoction), Dú Huó Jì Shēng Tāng (Pubescent Angelica and Mistletoe

Decoction), Wĕi Jīng Tāng (Phragmites Stem Decoction), Kŏng Shèng Zhĕn Zhōng Dān (Confucian’s Inside Pillow Elixir), and Zĭ Xuĕ Dān (Purple Snow Elixir). Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘 要), written after Sun’s two books, was another monumental work regarding formulas and clinical medicine. Wang Tao, the author, worked in the imperial library for more than twenty years. He read a huge amount of medical books not accessible by the public, and used his reading notes as reference while compiling his work. That is how the book got its title. It contains forty volumes, one thousand one hundred four categories, and some six thousand eight hundred formulas. A unique characteristic of the book is that it organized and restored many formulas from the eras before and up to the Tang Dynasty including those in Light Taste of Classic Formulas (Xiăo Pĭn Fāng, ⼩品⽅), Liu Juan-zi’s Ghost-Bequeathed Formulas (Liú Juān Zĭ Guĭ Yí Fāng, 刘涓⼦鬼 遗⽅), Fan Wang’s Formulas (Fàn Wāng Fāng, 范汪⽅), Monk Shen Shi’s Formulas (Shēn Shī Fāng, 深师⽅), Cui’s Formulas (Cuī Shì Fāng, 崔氏 ⽅), Collection of Empirical Formulas (Jí Yàn Fāng, 集验⽅), Formulas for Vast Relief (Guăng Jì Fāng, 广济⽅), and Recent Effective Formulas (Jìn Xiào Fāng, 近效⽅). Xu Da-chun of the Qing Dynasty praised Wang Tao “collected formulas from Han Dynasty forward, selected the great ones and compiled a complete book. [His] contribution should not be forgotten, for his work preserved formulas prior to the Tang Dynasty”[12]. The book still serves as an important reference for researching previous materials.

V. Song (960~1279 AD) and Yuan (1271~1368 AD) Dynasties The Song ended the abrupt, entangled war during the period of the Five Dynasties and Ten Kingdoms, and became a highly centralized feudal dynasty. The unity of the country and economic progress pushed science and culture forward to reach an unprecedented peak. This was also the case for medicinal formulas. Some emperors of the Northern Song Dynasty were fond of medicine and medicinal formulas. Zhao Kuang-yin, Emperor Taizu of Song, showed an interest of formulas and medicinals. He studied medical techniques and gathered more than one thousand practical formulas. At the beginning of the Song Dynasty, he issued “Edict for Inquiring Medicine Books”. It was not the only time during the Song Dynasty that such efforts by the central government were done at a national level to recruit medical books, investigate medicinal resources, sort them out, print, and publish books. It was ongoing even right before the royal court migrated to the south. Several emperors such as Emperor Taizong and Huizong had personally written prefaces or general discussions for formula books. At the same time, many scholastic government officials were actively involved in medical affairs and improving the prosperity of formula books during the Song Dynasty. In the second year of Jiayou Era (1057 AD), the Talent Convergence Academy established the Medical Book Emendation Bureau, the first national medical editorial and printing agency in Chinese history. With the popularization of woodblock printing and the invention of movable typography, it enabled medical and formula books to be printed much more conveniently. Consequently, the Song Dynasty became an

important period for gathering, emendating, and composing medicinal and formula books. During this period, the government published huge collective formula books such as Universal Rescuing Formulas of Marvelous Physicians (Pŭ Jiù Fāng, 普救⽅), Formulas from Benevolent Sages Compiled during the Taiping Era (Tài Píng Shèng Huì Fāng, 太平圣惠⽅), and Comprehensive Recording of Divine Assistance from the Zhenghe Era (Shèng Jì Zŏng Lù, 圣济总录). Besides, many individual works with distinctive characteristics were born. There were about one hundred twenty such works, such as Experiential Formulas for Universal Relief (Pŭ Jì Bĕn Shì Fāng,普济本事 ⽅) by Xu Shu-wei, Universal Relief Formula from Ji Feng (Jī Fēng Pŭ Jì Fāng, 鸡峰普济⽅) by Zhang Rui, Treatise on Diseases, Patterns, and Formulas Related to the Unification of the Three Etiologies (Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn, 三因极⼀病证⽅论) by Chen Yan, Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅) by Yan Yong-he, Wang’s Broad Relief Formulas (Bó Jì Fāng, 博济⽅) by Wang Yan, Fine Formulas of Su and Shen (Sū Shĕn Liáng Fāng, 苏沈良⽅) by Su Dong-po and Shen Kuo, [Yang] Ren-zhai’s Direct Guidance on Formulas (Rén Zhāi Zhí Zhĭ Fāng, 仁斋直指⽅) by Yang Shi-ying, and Important Formula Collection for Traveling and Dwelling (Lǚ Shè Bèi Yào Fāng, 旅舍备要⽅). Tang Shen-wei, a medical scholar of the Northern Song Dynasty wrote Materia Medica Arranged According to Pattern (Zhèng Lèi Bĕn Căo, 证类 本草), which recorded three thousand single medicinal formulas. It was the first to attach formulas in a medicinal book. The book also left behind a good number of precious empirical formulas.

The government of the Northern Song established the Taiping Benevolent Formula Bureau to standardize the production of patent formulas. This indicated that China entered a new stage in handling the marketing, sales, and management of galenical products and patent formulas. Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅), a dictionary of patent formulas was the first of its kind in Chinese history published by the government with revisions and editing of collected formulas. Wars during the Jin and Yuan period had a negative impact on the development of Chinese medicinal formulas. Nevertheless, many clinical medical professionals focused on researching and summarizing formulas. Major achievements were reflected in clinical books, with an exception of Effective Formulas from Generations of Physicians (Shì Yī Dé Xiào Fāng, 世医得效⽅) by Wei Yilin. Other specialized formula books included An Elucidation of Formulas (Xuān Míng Lùn Fāng,宣明论⽅) by Liu Wan-su, Zhang’s Empirical Formulas (Jīng Yàn Fāng, 经验⽅) and Secret Recording of Unusual Formulas (Mì Lù Qí Fāng,秘录奇⽅) by Zhang Cong-zheng, [Li] Dongyuan’s Proven Formulas (Dōng Yuán Shì Xiào Fāng, 东垣试效⽅) by Li Dong-yuan, Formulas to Keep in One’s Sleeve with Associated Extensions (Fù Guăng Zhŏu Hòu Fāng, 附广肘后⽅) by Yang Yong-dao, Elaboration on Formulas from the Imperial Pharmacy (Jú Fāng Fā Huī, 局⽅发挥) by Zhu Dan-xi, Formulas of Imperial Medicinal Dispensary (Yù Yào Yuàn Fāng, 御药院⽅) by Xu Guo-zhen, Collection of Medical Formulas (Yī Fāng Jí Chéng, 医⽅集成) by Sun Yun-xian, Forever Formulas with Official Seals (Yŏng Lèi Qián Fāng, 永类钤⽅) by Li Zhong-nan, and Great Collection of Medical Formulas (Yī Fāng Dà Chéng, 医⽅⼤成) by Chen Zi-jing.

Investigation regarding the meaning and reason behind formulas started in the Song Dynasty under the influence of “discovering knowledge via thorough investigation on matters”,[13] a theory brought out by idealist philosophers of a particular Confucius school. Cheng Wu-ji of the Jin State explained the organizational principles and relationships among medicinal combinations of twenty commonly used formulas from Treatise on Cold Damage in his book Concise Supplementary Exposition on Cold Damage (Shāng Hán Míng Lĭ Lùn, 伤寒明理论). For the first time in history, he initiated formula analysis expanding the scholastic topics of medicinal formulas. Medical professionals in the Song, Jin, and Yuan dynasties created a lot of novel and efficacious formulas. Liù Wèi Dì Huáng Wán (SixIngredient Rehmannia Pill), Dăo Chì Săn (Red-Guiding Powder), and Xiè Bái Săn (White-Draining Powder) were recorded in Qian Yi’s book called Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀). An Elucidation of Formulas (Xuān Míng Lùn Fāng, 宣明论⽅) by Liu Wan-su recorded Fáng Fēng Tōng Shèng Săn (Ledebouriella Sage-Inspired Powder) and Shuāng Jiĕ Săn (Dural Relieving Powder). Jiŭ Wèi Qiāng Huó Tāng (Nine Ingredients Notopterygium Decoction) was invented by Zhang Yuan-su and referenced in The Bewildering Matter (Cĭ Shì Nán Zhī, 此事难知) written by Wang Hao-gu. Li Dong-yuan elaborated the use of Bŭ Zhōng Yì Qì Tāng (CenterSupplementing and Qi-Boosting Decoction) and Dāng Guī Bŭ Xuè Tāng (Chinese Angelica Blood-Supplementing Decoction) in his Treatise on the Spleen and Stomach (Pí Wèi Lùn), and Pŭ Jì Xiāo Dú Yĭn (Universal Relief Toxin-Removing Beverage) in his Dong-yuan’s Proven Formulas. Zhu Dan-xi’s book Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

recorded Zuŏ Jīn Wán (Left Metal Pill), Dà Bŭ Yīn Wán (Major YinSupplementing Pill), and Èr Miào Săn (Two Mysterious Powder).

VI. Ming (1368~1644 AD) and Qing (1644~1911 AD) Dynasties Chinese medicinal formulas and medicinals have always been developing indivisibly, side by side. The understanding of medicinal efficacy is enriched every time a new formula is created or the subject of formulation progresses. At the same time, the deepening of formula analysis has emboldened the knowledge of the controlling factors of medicinal efficacy in multi-medicinal formulas. All of these further promote the application of clinical formulas and the prosperity of innovation. The Ming Dynasty was an immensely thriving period for not only medicinals, but also medicinal formulas. Different kinds of formula books were published. Among them, Formulas for Universal Relief (Pŭ Jì Fāng, 普济⽅) was the largest existing work edited and printed by the government. In addition, some were collections of simple yet effective formulas, some were summaries of previous experience, and some focused on recording empirical formulas and individual comprehension from their clinical practice. Some, such the first formula analytical specialty book Investigations of Medical Formulas Yī Fāng Kăo, 医⽅考) by Wu Kun, intended to explain the meaning of formulas. Primitive Prescriptions (Zŭ Jì, 祖剂), written by Shi Pei, focused on tracing back the origin and transformation of formulas. The subject of Chinese medicinal formulas was maturing during this period, in terms of the quantity of publications, quality of formula analysis, and the integration of theory, methods, formulas and medicinals.

The clinical medicine publications of the Ming Dynasty also included rich content about formulas. Standards for Diagnosis and Treatment Zhèng Zhì Zhŭn Shéng, 证治准绳), written by Wang Ken-tang has always been well known in medical circles for its broad collection of formulas. The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全书) by Zhang Jiebin, especially the chapters of Eight Treatment Strategies of New Formulas, contained innovative formulas that had significant impact on later generations. Many other physicians and medical scholars made unique contributions respective to medicinal formulas. Examples are Treatise on Warm-Heat Pestilence (Wēn Yì Lùn, 温疫论) by Wu You-ke, Mainstream Memoir of Medicine (Yī Xué Zhèng Zhuàn, 医学正传) by Yu Tuan, Restoration of Health from the Myriad Diseases (Wàn Bìng Huí Chūn, 万病 回春) by Gong Ting-xian, Symptoms, Causes, Pulses, and Treatment (Zhèng Yīn Mài Zhì, 症因脉治) by Qin Jing-ming, Primary Mirror of Rectifying Deficiency (Lĭ Xū Yuán Jiàn, 理虚元鉴) by Wang Yi-shi, Elaboration on External Medicine (Wài Kē Fā Huī, 外科发挥) by Xue Ji, Orthodox Lineage of External Medicine (Wài Kē Zhèng Zōng, 外科正宗) by Chen Shi-gong, and A Compendium of Female Disorders (Jì Yīn Gāng Mù, 济阴纲⽬) by Wu Zhi-wang. These physicians also created a large number of new formulas still being used today, such as Wang Ken-tang’s Sháo Yào Săn (Peony Powder) and Sì Shén Wán (Four Spirits Pill), Xue Ji’s Bā Zhēn Tāng (Eight-Gem Decoction), Hong Jiu-you’s Tiān Wáng Bŭ Xīn Dān (Celestial Emperor Heart-Supplementing Elixir), Han Mao’s Sān Zĭ Yăng Qīn Tāng (Three-Seed Filial Devotion Decoction), Wu You-ke’s Dá Yuán Yĭn (Membrane-Source Reaching Beverage), Chen Shi-gong’s Tòu Nóng Săn (Pus-Expelling Powder) and Xiāo Fēng Săn (Wind-Dispersing Powder), Yu Tuan’s Jiŭ Xiān Săn (Nine Immortals Powder), and Miao Xi-

yong’s Zhú Yè Liŭ Bàng Tāng (Lophatherum, Tamarisk and Arctium Decoction). In addition, associated formulas attached in medicinal books were a phenomenon. In The Grand Compendium of Materia Medica (Bĕn Căo Gāng Mù, 本草纲⽬) alone, there were more than 11,000 simple and empirical formulas. The content in those books were not only a component of Chinese medicinal formulas, but also the enhancement of the link between formulas and medicinals. Even though the Qing Dynasty did not leave behind any major formula masterpiece, there were a few unique characteristics and achievements. First of all, the formula books written in Qing Dynasty were not comprehensive. Rather, the trend was backing out from abundance into simplicity. Empirical formulas extracted from outstanding medical prescriptions across diverse schools brought forth the creation of a great deal of formula poems for easier chanting and memorizing. Those poems were mostly welcome by medical students and clinical physicians. They were popular enough that some are broadly used even now and they further promoted the prevalence of the knowledge of Chinese medical formulation. There were about three hundred types of books regarding empirical or single medicinal formulas with an increase in publication; this was a unique characteristic of the Qing formula books. However, the quality of many of those books was average at best. Second, it was a general trend for the people of the Qing Dynasty to explain the meaning of formulas following the publication of Investigations of Medical Formulas (Yī Fāng Kăo, 医⽅考). A great deal of monographs in medicinal formulation came forth, such as Discussion on Famous Physicians’ Formulas (Gŭ Jīn Míng Yī Fāng Lùn, 古今名医⽅论) by Luo

Mei, Selected Commentaries to Ancient Formulas from the Crimson Snow Garden (Jiàng Xuĕ Yuán Gŭ Fāng Xuăn Zhù, 绛雪园古⽅选注) by Wang Zi-jie, Treatise on Medical Formulas (Yī Fāng Lùn, 医⽅论) by Fei Boxiong, and Discussion on Famous Physicians’ Formulas with Removals and Additions (Shān Bŭ Míng Yī Fāng Lùn, 删补名医⽅论) by Wu Qian. During this period, formula books made a huge progress and an extraordinary achievement in the study of composition theory, formula analysis, and combination relationships. In addition to practical books such as Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ,医⽅集解) with a focus towards an elaboration of the above subjects, scholars of classic medical intensively studied and canonized the formulas of Zhang Zhong-jing. This directly accelerated indepth explanations of formulas and promoted the practical usage of them. For example, Ke Yunbo had a section titled “Grand Principles for Formula Composition” in Appendices to the Treatise on Cold Damage (Shāng Hán Lùn Yì, 伤寒论翼), which discussed applicable patterns, treatment methods, and formula composition of the formulas in Treatise on Cold Damage. Xu Ling-tai had six chapters of his own understanding of formula theories in Treatise on the Origin and Development of Medicine (Yī Xué Yuán Liú Lùn, 医学源流论). Both had novel insights that served as guidelines up until modern age to certain extent. Many medicinal books were not limited by simply attaching formulas when explaining a medicinal. They integrated formulas when discussing medicinals along with a comparison and an analysis. Consequently, formula and medicinals were elaborated coherently, so that both subjects were able to advance at the same time. Many book titles seem to discuss medicinals, but in fact elaborate formulas. Examples include, Explanation of Medicinals from Changsha (Cháng Shā Yào Jiĕ, 长沙药解) and Yu-Qiu’s Explanation

of Medicinals (Yù Qiū Yào Jiě, ⽟楸药解) of Huang Yuanyu and Records of Thoughtful Differentiation of Materia Medica (Bĕn Căo Sī Biàn Lù, 本草思 辨录) by Zhou Yan. These reveal that the cohesive prosperity of formulas and medicinals had become a distinct characteristic in Chinese medicine at the time. Third, the format of formula books changed during the Qing Dynasty. The actions of a medicinal became listed first, followed by its indications. This happened as the actions were investigated among the defined indications and then listed separately when describing a medicinal. There was an advancement regarding treatment methods and theories as well. The classification of formula books is based on the indications and treatment methods, which is the origin of modern Chinese formulation. Moreover, a number of collective medical books, book series, medical encyclopedia, and empirical works published in Qing Dynasty made boundless contributions in terms of conserving historic literature and materials regarding Chinese formulas. These include Grand Compendium of Ancient and Current Books−Complete Records of Medical Works (Gŭ Jīn Tú Shū Jí Chéng-Yī Bù Quán Lù, 古今图书集成·医部全录), Complete Library of the Four Treasuries (Sì Kù Quán Shū, 四库全书), Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴), Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温病条辨), and Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟). For example, Formulas for Universal Relief (Pŭ Jì Fāng, 普济⽅) was fortunately preserved because of the citation of Complete Library of the Four Treasuries (Sì Kù Quán Shū, 四库全书). The Qing Dynasty was a period of continuing development regarding formulation theories as well as the creation of new formulas from accumulated precious experience. The warm disease school, for example, invented new treatment methods such as releasing the exterior

with acrid-cool medicinals, clearing the ying level and cooling the blood, extinguishing wind and subduing yang, and resolving toxins and opening the orifices. Many corresponding formulas were created, including Yín Qiào Săn (Lonicera and Forsythia Powder), Qīng Yíng Tāng (Ying Level HeatClearing Decoction), Zhĭ Sòu Săn (Cough-Stopping Powder), Bŭ Yáng Huán Wŭ Tāng (Yang-Supplementing and Five-Returning Decoction), Tōng Qiào Huó Xuè Tāng (Orifice-Unblocking and Blood-Invigorating Decoction), and Yáng Hé Tāng (Harmonious Yang Decoction). These innovative methods and formulas provided rich soil for the modern development of Chinese formula. Two of the main empirical formula books from the Qing Dynasty are Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ, 医⽅集解) and Effective Use of Established Formulas (Chéng Fāng Qiè Yòng, 成⽅切⽤). Wang Ang who lived in early Qing Dynasty was the author of Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ, 医⽅集解). He wrote the book due to the fact that the formula books available at the time only discussed a mapping from formula to a disease, but “not explaining thoroughly about the cause of the illness, and which channel or collateral the disease was affecting. [They] did not explain the nature, flavor, actions, or the pertaining channels and collaterals indicated for such diseases”[14]. He selected three hundred seventy-seven major and four hundred eightyeight associate formulas and provided detailed elaboration to “discuss the cause of the disease first, then explain why certain medicinals were used followed by various famous comments [of the formula], and finally, address the applications and contraindications”[15]. The formulas it recorded were composed of relatively fewer ingredients. “If the formula contains more than twenty medicinals, it will

not be chosen”. Most were practical with definite effects. For each category, the primary formula was explained first, followed by associated ones with similar functions. Distinct prioritization, clear evolution, and rational modifications made it easy to grasp and relate to. It classified formulas into twenty-one categories. The main actions are deficiencyreplenishing, exterior-releasing, vomit-inducing, internal excess-purging, winddispersing, colddispelling, heat-clearing, dampness-resolving, drynessmoistening, and fire-draining. The book pioneered a unique approach to comprehensive classification by combining the disease cause, treatment method, and clinical specialty. Wang’s discourse on formulas completely covered aspects of pattern manifestations, pathogens, pulse characteristics, zang-fu organs, channels and collaterals, medicinal properties, and treatment methods with plain and smooth text easy for novices to study, and gained widespread popularity. Thereafter, Wu Yi-luo combined the merits of both Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ, 医⽅集解) and Investigations of Medical Formulas (Yī Fāng Kăo, 医⽅考). He removed the redundancies, added important content, modifications, and applications. The book was named Effective Use of Established Formulas (Chéng Fāng Qiè Yòng, 成⽅ 切⽤), a book with equivalent popularity. It has a collection of more than one thousand formulas follows Wang’s classification method comprehensively with twenty-four categories. In addition to the above, there were other commonly used formula reference books from that time, such as Summary Verses of Post-classical Formulas Shí Fāng Gē Kuò, 时⽅歌括), Ingenious Uses of Post-classical Formulas Shí Fāng Miào Yòng, 时⽅妙⽤), Summary Verses of Categorized Cold Damage Formulas (Shāng Hán Lèi Fāng Gē Kuò, 伤寒类⽅歌括) and Summary Verses of Golden Cabinet Formulas Jīn Guì Fāng Gē Kuò, ⾦匮

⽅歌括) written by Chen Xiu-yuan, and Convenient Reader on Established Formulas (Chéng Fāng Biàn Dú, 成⽅便读) by Zhang Bingcheng.

VII. Modern Times In modern times, especially after new China was founded, the development of Chinese medicinal formulation accelerated. During the past sixty years, a large amount of important formula books from the past were revised, photocopied, edited, and finally published. They include Formulas to Keep in One’s Sleeve (Zhŏu Hòu Bèi Jí Fāng, 肘后备急⽅), Light Taste of Classic Formulas (Xiăo Pĭn Fāng, ⼩品⽅), Important Formulas Worth a Thousand Gold Pieces (Qiān Jīn Yào Fāng, 千⾦要⽅), Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘要), Formulas from the Imperial Pharmacy (Hé Jì Jú Fāng, 和剂局⽅), Comprehensive Recording of Divine Assistance Shèng Jì Zŏng Lù, 圣济总录), and Formulas for Universal Relief (Pŭ Jì Fāng, 普济⽅). This has provided great convenience for the study of ancient formulas as well as the history of the subject. There are a lot of newly edited books, dictionaries, and other reference books that have become available and contain past, present, or empirical formulas. A typical example would be Encyclopedia of Chinese Medicinal Formulas (Zhōng Yī Fāng Jì Dà Cí Diăn, 中医⽅剂⼤辞典) edited by Nanjing University of Traditional Chinese Medicine. The dictionary contains eleven fascicules, eighteen million Chinese characters and ninety six thousand five hundred ninety-two formulas along with their history. The work is a grand collection of the achievements of Chinese medicinal formulas. It contains tremendous content that was rigorously researched and examined. It is the first of its kind as a large-scale formula book and reached a fairly high level after Formulas for Universal Relief (Pŭ Jì Fāng, 普济⽅) published in early years of Ming Dynasty.

Along with the ongoing advancement of higher education in Chinese medicine over the past a half century, there are continuously updated educational materials published and used in Chinese formula studies including texts and teacher’s reference books. At the same time, many topics are being studied such as treatment principles, treatment methods, composition principles, combination rules, and multi-medicinal effects. The approach of these studies includes a great deal of modern laboratory experimentation, literature research, and clinical observations. As a result, formulation theories have reached a deeper level expanding the formula applications. There has been enormous advancement in the division of Chinese pharmaceutical preparation, production engineering of patent formulas, formulation types, medicinal efficacy, pharmacology, toxicology, quality standards, and clinical applications. New products have been successfully created with continuous improvement and updates regarding the forms of formulas, facilities, technologies, and inspection measures. Formulas that have gained official recognition and are agreeable in terms of industry have been increasing over recent years. Along with the development of Chinese medicine in all aspects, the unique advantages offered by Chinese medicinal formulas contribute to the health and wellness of human beings.

Endnotes: [1] 善⾔古者，必有验于今 [2] 谨调阴阳，以平为期 [3] 治病必求于本 [4] 治求其属 [5] 主病之谓君，佐君之谓臣，应臣之为使 [6] 勤求古训，博采众⽅ [7] ⽅书之祖 [8] 单⾏径易，约⽽易验;篱陌之间，顾眄皆药;众急之病，无不毕 备;家有此⽅，可不⽤医 [9] 伤寒与天⾏温疫为异⽓ [10] 伤寒及温病……内瘀有蓄⾎者 [11] 能⽤食平疴、释情遗疾者，可谓良⼯ [12] 纂集⾃汉以来诸⽅，汇萃成书，⽽历代之⽅于焉⼤备……唐 以前⽅赖此以存，其功亦不可泯 [13] 格物致知 [14] 未尝发明受病之因，及病在某经某络……亦未尝发明药之⽓ 味功能，入某经某络，所以能治某病之故 [15] 先评受病之由，次解⽤药之意，又博采硕论名⾔，分别宜⽤ 宜忌

CHAPTER 2 Treatment Methods and Formulas Section 1 Overview of Treatment Methods Treatment methods and formulas are both important components of the comprehensive traditional Chinese medical system that incorporates theory, treatment methods, formulas, and medicinals. Treatment according to pattern differentiation in clinical practice is a sequential process from problem analysis to problem solving. Only if the pattern is differentiated correctly will the appropriateness of the treatment be clear and specific as well as the formula and medicinals be in accord with the treatment method. With these in line one can achieve the expected efficacy. Therefore, the treatment method is the link between pattern differentiation and formula composition, as well as, the foundational prerequisite to the study and application of Chinese medicinal formulas. Treatment method is defined as the appropriate therapeutic rules after clarifying the pattern, root cause, and disease mechanism. In the early era of The Yellow Emperor’s Inner Classic, there were records of rich theories regarding treatment methods. For example, in Basic Questions-Grand Discussion of Yin-Yang in Response to the Nature and Body (Sù Wèn-Yīn Yáng Yìng Xiàng Dà Lùn,素问·阴阳应象⼤论), it states “treat physical

insufficiency by warming to nourish the qi. Essence insufficiency should be treated with thick-flavored tonics. Disease in the upper body demands emetic therapy. Pathogens in the lower jiao require dredging. Abdominal fullness needs elimination. For those having [contracted with] external pathogens, soak the body [with decoction] to promote sweating; for those [with the pathogen] on the surface, induce sweating to release [the pathogens].”[1] Basic Questions-Grand Discussion on Most Important Truth and Essentials (Sù Wèn-Zhì Zhēn Yào Dà Lùn, 素问·至真要⼤论) recorded many methods such as “treat cold with heat, treat heat with cold; treat mild conditions with counteraction, treat severe conditions with co-action, treat hardness by whittling, intruding [pathogens] should be expelled, treat overworking with warmth; treat accumulation with dissipation, treat retention with purgation, treat dryness with moistening, treat tension with relaxation, treat dissipation with astringency, treat detriment with enrichment; treat inactivity with mobility, and treat fright with calming. [Others include] vomiting, purging, massaging, bathing, patching, robbing, opening, and diffusing”[2]. This built a good foundation for the treatment theories of Chinese medicine. From then till the end of the Han Dynasty, Zhang Zhong-jing was “diligently seeking ancient precepts and collecting a wide range of formulas”. Being the saint of Chinese medicine, he innovatively integrated treatment methods with formulas and their applicable patterns, and summarized a complete treatment system based on pattern differentiation. Medical professionals and scholars later in history further enriched the theories with continual summaries of clinical experience, which diversified the content of treatment methods to make them more applicable in treating all kinds of diseases and patterns.

Treatment methods in Chinese medicine can be summarized into two levels. First, a method that is generalized for a certain category of disease mechanisms is called a grand treatment principle. Examples include inducing a sweat for exterior patterns, warming for cold patterns, clearing for heat patterns, supplementing for deficient patterns, and draining for excess patterns. The “eight medicinal treatment methods” discussed in this book under “common treatment methods” fit into this level. Second, the method indicated for a specific pattern is the specific treatment method. The “actions”section of each formula discusses its relevant specific treatment method. It is only with a precise grasp of each specific treatment method can one obtain a greater level of pertinence when treating specific disease patterns in clinical practice. Another characteristic method used in Chinese medical treatment, in addition to multiple levels, is the multiple systems method. During its long development, Chinese medicine formed quite a few pattern differentiation systems based on clinical experience. Pattern differentiation systems include zang-fu, six-channel, four-level, triple-jiao, and channel-collateral diagnosis. Due to the coherence between a treatment method and the disease mechanism, different treatment systems were formed. “Diffusing the lung to relieve cough” and “nourishing water to moisten wood”pertain to the zang-fu pattern differentiation system while “harmonizing shaoyang” and “draining and purging heat accumulation from yangming“ are within the six-channel differentiation system. Methods such as “clearing qi-level heat” and “clearing ying-level heat and cooling blood” both fall into the four-level differentiation system. “Diffusing upper, unblocking middle, and percolating lower” and “divide three jiao to disperse [pathogens]” both pertain to the triple-jiao differentiation system.

When we are studying and applying these systems, we must carefully relate them to the fundamental theory of disease mechanisms. It is the only way that one will be able to pinpoint the disease mechanism and thereby apply the specific treatment method(s), compose the correct formula, and use the appropriate medicinals.

Section 2 Correlation Between Formulas and Treatment Methods The use of Chinese formulas is an important method to treat diseases in clinical practice. A formula is the product of medicinal selection, appropriate combinations based on pattern differentiation, and the adherence to the treatment principles. Only when we understand the relationship between a formula and its corresponding treatment method, can we correctly combine medicinals to compose and apply formulas or patented formula products. By observing the formation and development of Chinese medicine, treatment methods were accumulated from continuous enrichment and improvement of the empirical knowledge of formulas, medicinals, and human physiology and pathology. The theory of treatment methods formed after the use of formulas and medicinals. However, once empirical methods became theories, they became the guiding principles used for composing formulas and the application of patent formulas. As an example, a patient with a common cold is examined by the four examination methods (inspection, listening and smelling, inquiry, and palpation) and is then diagnosed with an exterior wind-cold pattern based on the differential analysis. The patient’s condition should be treated by the sweating method because of the exterior pathology and the warming method for the cold pathology. These belong to the grand treatment method. In this case, the treatment method is to release the exterior with acrid-warm medicinals. So an appropriate formula should be selected or composed. If

the patient takes the formula and it induces a sweat and releases the exterior, the pathogenic factor will be dispelled and he/she will recover. Otherwise, if the treatment method does not agree with the pattern differentiation, or the formula composition does not agree with the treatment method(s), the treatment will not be effective or it may even worsen the condition. Obviously, the goal of pattern differentiation is to determine the disease mechanism; while the key of the treatment plan is to determine the correct treatment method. The principle for selecting medicinals to compose a formula is that the treatment method must pertain to the disease mechanism. The formula serves as the vehicle which corresponds with and fulfills the requirements of the treatment method. Although we often hear that “a formula is completed by its medicinals”[3], we must first address that “a formula comes out of the treatment method, and a treatment method results from the pattern”[4]. Therefore, a formula and a treatment method are closely related to and reinforce each other. In addition to composing or applying formulas according to treatment methods, the correlation between a formula and a treatment method can be seen in formula classification and explained by the treatment methods. Formula classification will be discussed in the corresponding section of Chapter Three and the latter will be reflected in each chapters of the second part of this book. Based on treatment methods, the four aspects of composing, applying, classifying, and explaining formulas made up the complete system of “grouping formulas based on treatment principles” that has been emphasized in Chinese medicine from the past till the present.

Section 3 Commonly Used Treatment Methods Because of the great variety of specific treatment methods, even though they are each pertinent to different treatment systems, Chinese medical professionals of different eras generalized and categorized them into different levels based on their commonalities. The “eight medicinal treatment methods”, which we often refer to, are high level principles summarized by Cheng Zhong-ling of the Qing Dynasty. In Medical Revelations-Eight Treatment Methods of Medicine (Yī Xué Xīn Wù-Yī Mén Bā Fă, 医学⼼悟·医门八法), Cheng wrote “in discussing the disease sources, they [could] be generalized into internal damage and exterior contraction. In discussing the disease conditions, they [could] be summarized into eight words, cold, heat, deficiency, excess, exterior, interior, yin and yang. [For] formulas treating diseases, they [could] be summed up into eight principles, sweating, harmonizing, purging, dispersing, vomiting, clearing, warming and supplementing”[5]. The “eight medicinal treatment methods” are hereby introduced as follows.

1. Sweating Sweating refers to the method of sweat promotion. It works by opening the striae and interstitial spaces, unblocking the flow of ying and wei, and diffusing lung qi to release any of the six exterior pathogens by inducing sweating. Sweating itself is not the goal of the method, but is rather a means to flush out pathogens via sweat. When the pathogens are released, the zheng qi can return to a balanced level where the striae and

interstitial spaces are open, the ying and wei are harmonized, the lung qi is unrestricted, and the blood vessels are not blocked. Besides treating exterior patterns caused by any of the externally contracted six pathogens, the sweat promotion method can be applied in situations characterized by cold or heat patterns with blocked striae and interstitial spaces, stagnant ying and wei, and an absence of sweat or loose striae and interstitial spaces with sweating. Examples are measles in the early breakout stage with indistinct rashes, edema with swelling mostly above the lumber, sores at an early stage with an aversion to cold and fever, and early stages of malaria or dysentery with exterior cold or heat patterns. On the other hand, due to different disease manifestations such as cold or heat, complications with mixed pathogens, strong or weak body constitutions, the sweat promotion method is divided into the acridwarm and acrid-cold categories which may be combined with other methods such as supplementing, purging, or dispersing.

2. Vomiting The vomit induction method uses emetics to disgorge stagnated phlegm, undigested food, or poisons residing in the pharynx, larynx, chest, diaphragm, and stomach. It is applicable for excessive phlegm in stroke cases, undigested food blocking the stomach, poisons in the stomach, mania, or pharyngitis due to excessive phlegm, or dry cholera with no vomiting and diarrhea. The determinants for inducing vomiting require that the location of the disease will be in the stomach or above, the situation is acute and urgent, the internal pathogen is excessive, and the patient has a strong constitution. In fact, because vomiting induction tends to damage stomach qi, it must be used with caution. It is especially true for those with a weak constitution, postpartum, or pregnant.

3. Purging The purgative method exerts its effective through purging, cleansing, and expelling undigested food, stercoroma, cold accumulation, stagnant blood, congested phlegm, and water retention lodged in the gastrointestinal tracts through the lower orifices in order to remove them. It is applicable as long as the pathogenic factor is located in the gastrointestinal system causing excessive patterns with constipation, accumulation of dry stool, watery discharge due to retained heat, stagnant phlegm, retention of water, stagnant blood, or accumulation of fluids. Since the disease pattern can be either hot or cold and the zheng qi can be deficient or sufficient, the pathogenic factors can complicate one another. Therefore, the purgative method includes not only cold, warm, and moistening purgation, but also purgation for expelling water, and purgation with supplementation. It may also be combined with other treatment methods.

4. Harmonizing The harmonizing method resolves pathogens that are half-exterior half-interior or treats imbalances of the zang-fu organs, yin-yang, or exterior-interior. Concise Supplementary Exposition on Cold Damage (Shāng Hán Míng Lĭ Lùn, 伤寒明理论) states that “for cold damage with exterior pathogenic factors, sweating must be used. If the pathogen is interior, it is beneficial to cleanse it thoroughly. If it is neither internal nor external but rather half-exterior, half-interior, either sweating or purging is appropriate. In this situation, harmonizing should be used”[6]. As we can see, the harmonizing method is specially designated for patterns with pathogens that have lodged halfway through.

In terms of the specific methods of harmonization, Dai Tian-zhang wrote in Treatise on Widespread Warm Pestilence Guăng Wēn Yì Lùn, 广瘟 疫论) that “combining hot and cold medicinals, mixing supplementing and draining, treating both exterior and interior, and calming excessive ebullience are all means of harmonizing”[7]. The harmonizing method, being neither too cold nor too warm, can expel pathogens and regulate the function of the zang-fu organs by taking the overall situation into consideration and offering a gentle remedy. It is appropriate for treating pathogenic qi attacking the shaoyang, liver-spleen disharmony, cold intestines and hot stomach, disharmony of qi-blood, and disharmony of ying-wei. Harmonizing has a broad range of applications with a variety of specific techniques. They mainly include harmonizing the shaoyang, opening up interior-exterior interspaces, coordinating the liverspleen, soothing the liver while harmonizing the stomach, dispersing pathogens from the upper and the lower simultaneously, and harmonizing the intestines and stomach. Moreover, in regards to the Treatise on Cold Damages, mild formulas or small doses of drastic formulas that are used to remove residual pathogens without hurting zheng qi are appropriate for disease patterns with pathogens that have lingered after promoting sweat, inducing vomit, or purging; or following spontaneous vomiting or diarrhea. This can be understood as an extended harmonizing method, which is different from the mediating and harmonizing methods we will be discussing here.

5. Warming The warming method exerts its effect by warming the interior in order to remove cold. It is used for treating conditions caused by interior cold.

Patterns of interior cold have two fundamental causes, external pathogenic contraction and internal damage. The earlier is the result of a direct interior attack of pathogenic cold, while the latter is damage of yang qi due to incorrect treatment, the absence of treatment, or by constitutional yangdeficiency that leads to internal cold. In addition, there are differences in terms of depth and the levels of severity. Consequently, the subcategories include warming the center to remove cold, restoring yang to rescue it from escaping, and warming the channels to dissipate cold. Due to the formation and developmental process of an interior cold pattern, yang deficiency and coldness may co-exist. This situation dictates the combination of the warming and supplementing methods for treatment. Exterior cold patterns that result from exterior cold attacking the superficial level that require the use of the acrid-warm exterior releasing method are not part of the warming method; it is a pathological situation addressed by sweating.

6. Clearing The clearing method is used to clear internal pathogenic heat by clearing heat, draining fire, resolving toxins, and cooling blood. It is applicable to patterns of internal heat, excessive fire, heat toxin, and yindeficient heat patterns. Since heat can be at the qi, ying, or blood levels, they can accumulate toxins and affect a certain zang-fu organ. The heatclearing method can be further classified as qi-level heat-clearing, yinglevel clearing with blood-cooling, heat-clearing with toxinresolving, zangfu organ heat-clearing, and so on. Heat patterns tend to damage yin and fierce heat tends to deplete qi. Therefore, fluid-engendering and qi-boosting medicinals are often added to

coordinate with other medicinals when composing a heat-clearing formula. At the late stages of warm disease, there could be yin damage because of the excessive heat, or insidious internal heat due to chronic illness caused by yin-deficiency. In this situation, heat-clearing should be combined with the yin nourishment method rather than directly using only bitter-cold medicinals. They would further depress the heat instead of completely resolving it. Exterior heat patterns and heat in the wei level can be resolved using acrid-cool exterior releasing medicinal. This is actually an application of the sweating method and therefore is not related to the clearing method.

7. Dispersing The dispersion method includes techniques such as promoting digestion to remove food stagnation, moving qi while quickening blood, dissolving phlegm along with promoting urination, and expelling worms in order to accumulate qi, blood, phlegm, food, water and worms. It is the appropriate treatment method for food retention, qi stagnation with blood stasis, lower abdominal masses, lodged water-dampness, untransformed phlegm-rheum, infantile malnutrition with accumulation, worm accumulation, excessive ulcerated sores, abscesses, and swollen carbuncles. Although the dispersing and purging methods both treat solid pathogens that have accumulated internally with an excessive nature, their applications are different. The purging method is proper for disease patterns involving urgent tangible pathogens in the gastrointestinal area that must be purged through the bowel without delay. The dispersing method, on the other hand, is appropriate for diseases of the zang-fu organs, channels, and muscles when the pathogen and disease are stubborn, gradually

accumulating, and often mixed with excessiveness and deficiency. The dispersing method should be used over a period of time when the accumulation of qi or blood forms lower abdominal masses, lumps, phlegm nodes, or scrofula that cannot be removed quickly. Dispersion is often combined with supplementation, purging, warming, and clearing in applicable conditions while the goal is to disperse the pathogenic factors.

8. Supplementing The supplementing method is indicated for all kinds of deficient patterns by boosting qi, blood, yin and yang of the human body. The goal of supplementation is to adjust the disturbance of qi, blood, yin and yang, or zang-fu organs back to balance using tonic and nourishing medicinals. In addition, when zheng qi is too weak to expel pathogenic qi, supplementation can be combined with other methods to boost zheng qi and dispel the pathogens. Although supplementing method may indirectly dispel pathogens, it should be used when externally contracted pathogen is absent to void the drawback of “keeping the gangster inside the home”[8]. There are quite a few specific methods under the category of supplementation with different aspects including qi, blood, yin, yang, or a particular zang-fu organ. At the same time, the method has taken the respective zang-fu organ or organs into consideration while a specific method such as boosting qi, nourishing blood, enhancing yin or supplementing yang is planned. In summary, the eight treatment methods are applicable to different patterns by differentiating between exterior-interior, heat-cold, and deficient-excess. In most disease patterns, the situation is usually complicated. A single treatment method is not sufficed for these cases and a

combination of the methods should be utilized for thorough care without leaving latent issues. Therefore, the combinations of the eight methods make a diverse treatment system. It is exactly as it stated in Cheng Zhong-ling’s Medical Revelations, “one [treatment] system provides eight [treatment] methods; and the eight methods provide hundreds of methods.”[9] Therefore, in clinical practice, we must aim at the specific disease pattern and use the eight methods with flexibly while prescribing a formula so that it can address the disease condition precisely in order to ensure treatment efficacy.

Endnotes: [1] 形不⾜者，温之以⽓︔精不⾜者，补之以味。其⾼者，因⽽越 之︔其下者，引⽽竭之︔中满者，泻之于内。其有邪者，渍形以为 汗︔其在⽪者，汗⽽发之 [2] 寒者热之，热者寒之，微者逆之，甚者从之，坚者削之，客者 除之，劳者温之，结者散之，留者攻之，燥者濡之，急者缓之，散者 收之，损者益之，逸者⾏之，惊者平之，上之下之，摩之浴之，薄之 劫之，开之发之 [3] ⽅以药成 [4] ⽅从法出，法随证⽴ [5] 论病之源，以内伤、外感四字括之。论病之情，则以寒、热、 虚、实、表、⾥、阴、阳八字统之。⽽治病之⽅，则又以汗、和、 下、消、吐、清、温、补八法尽之 [6] 伤寒邪在表者，必渍形以为汗︔邪在⾥者，必荡涤以为利︔其 于不内不外，半表半⾥，既非发汗之所宜，又非吐下之所对，是当和 解则可矣 [7] 寒热并⽤之谓和，补泻合剂之谓和，表⾥双解之谓和，平其亢 厉之谓和 [8] 闭门留寇 [9] ⼀法之中，八法备焉，八法之中，百法备焉

CHAPTER 3 Classification of Formulas Based on their views, Chinese medical professionals throughout history created many classification systems for Chinese formulas. Some major classifications were based on “seven kinds of formulas” theory, disease patterns, formula origins, actions, and comprehensive classification.

I. Classification Based on the “Seven Kinds of Formulas” Theory “The seven kinds of formulas” theory can be traced back to the Yellow Emperor’s Inner Classic. In Basic Questions-Grand Discussion on Most Important Truth and Essentials (Sù Wèn-Zhì Zhēn Yào Dà Lùn, 素问·至真 要⼤论), it states that “one chief and two deputies control mild [conditions]. One chief, three deputies and five assistants control moderate [conditions]. One chief, three deputies and nine assistants control complicated [conditions]”[1]. “One chief with two deputies is odd [number] controlling. Two chief with four deputies is even [number] controlling. Two chiefs with three deputies is odd [number] controlling. Two chiefs with six deputies is even [number] controlling.”[2] “Supplementing and treating upper [body] use moderate controlling. Supplementing and treating lower [body], use speedy controlling. Speedy [formulas] have heavier taste, and moderate [ones] have lighter taste.”[3] “Smaller quantity [should be used] to control

[problems] with closer distance, and larger quantity [should be used] to control [problems] with further distance, [whether it is] odd or even number [of medicinals]. [A formula with] larger quantity contains fewer medicinals and [that of with] smaller quantity contains more medicinals. Nine can be considered more, and two can be considered less. If an odd number formula does not work, then use an even number one.”[4] This is the earliest record of the “seven kinds of formulas”. By analyzing the relevant content of the Basic Questions-Grand Discussion on Most Important Truth and Essentials (Sù Wèn-Zhì Zhēn Yào Dà Lùn, 素问·至真要⼤论), these statements were actually a summarization of how to compose formulas according to the momentum of the pathogens, the exterior-interior location of the disease, the severity of the condition, the genetic constitution of the body, and the requirements of the treatment. Therefore, it was not for the purpose of formula classification. It wasn’t until the Jin Dynasty that Cheng Wu-ji clearly brought up the concept of “seven kinds of formulas” in his book Concise Supplementary Exposition on Cold Damage (Shāng Hán Míng Lĭ Lùn, 伤寒明理论). He explained “to apply the formula preparations, there were seven kinds of formulas that are giant, small, slow, rapid, odd, even and complex”[5] and changed “heavy (zhòng)”found in The Yellow Emporer’s Inner Classic to “complex (fù)”. The successors extended the underlying meaning and used it as the earliest classification method of formulas. Although Cheng pioneered the theory of “seven kinds of formulas”, he did not follow it in Concise Supplementary Exposition on Cold Damage (Shāng Hán Míng Lĭ Lùn, 伤寒明理论), but used it as the citation while analyzing certain formulas. Even until today, there is no formula book found to incorporate it.

Therefore, it is purely a school of formula compositional theory from antiquity.

II. Classification Based on Disease Patterns Formulas for Fifty-two Diseases (Wŭ Shí Èr Bìng Fāng, 五⼗⼆病⽅) was the first formula book classified based on disease patterns. The book recorded fifty-two diseases and two hundred eightythree formulas that covered conditions pertaining to internal, surgical, gynecology, pediatric, and ophthalmology and otorhinolaryngology departments. The compositions of the formulas were simple without precise quantification of the medicinals, and some of the names of disease and medicinals could not be identified. As the result, the book cannot serve as a clinical guide. Representative works using disease patterns to classify formulas include Treaties on Cold Damage and Miscellaneous Diseases by Zhang Zhong-jing of the Han, Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘要) by Wang Tao of the Tang, Formulas from Benevolent Sages Compiled During the Taiping Era (Tài Píng Shèng Huì Fāng, 太平圣惠⽅) by Wang Huaiyin of the Song, Formulas for Universal Relief (Pŭ Jì Fāng, 普济⽅) by Zhu Di, an emperor of the Ming, Comprehensive Medicine According to Master Zhang (Zhāng Shì Yī Tōng, 张氏医通) by Zhang Lu and Medical Standards of the Han Dynasty (Lán Tái Guĭ Fàn, 兰台轨范) by Xu Da-chun of Qing Dynasty. Such classification methods provide the convenience in clinical practice to search for a formula based on disease patterns. Disease patterns based on formula classifications include different approaches; for example, according to zang-fu disease patterns or etiology. Some books combined disease patterns with corresponding treatment methods as the classification approach such as Important Formulas Worth a

Thousand Gold Pieces for Emergency Bèi Jí Qiān Jīn Yào Fāng, 备急千⾦ 要⽅), Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台 秘要), and Treatise on Diseases, Patterns, and Formulas Related to the Unification of the Three Etiologies Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn, 三 因极⼀病证⽅论).

III. Classification Based on the Origin of the Formulas Origin of Prescriptions (Zŭ Jì, 祖剂), written by Shi Pei of the Ming Dynasty, contains selected fundamental formulas and placed similar ones into each category from The Yellow Emperor’s Inner Classic, Treaties on Cold Damage, Essentials from the Golden Cabinet, Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太 平惠民和剂局⽅), and those created by physicians after the Taiping era of the Song Dynasty. In additional to listing formulas based on disease causes and patterns, Comprehensive Medicine According to Master Zhang (Zhāng Shì Yī Tōng, 张氏医通) has a separate volume named Original Formulas (Zŭ Fāng, 祖⽅) that has chosen thirty-four classic formulas and attached derivative prescriptions under each one. This classification method serves a good tool for the conclusive study of similar disease mechanisms and treatment methods. The drawback, on the other hand, is that it cannot really trace back the origin nor the starting and ending points. For instance, Èr Chén Tāng (Two Matured Substances Decoction), a formula in Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) of Song Dynasty was seen as the base formula, and Wēn Dăn Tāng (GallbladderWarming Decoction) of Tang Dynasty as an associated formula (note: Tang Dynasty was an earlier era than Song Dynasty).

IV. Classification Based on Actions and Treatment Methods The action of a formula reflects its corresponding treatment method. Thus, formula classifications based on treatment methods developed and matured out of action-based categorization with the latter derived from the “ten prescriptions” theory. In Supplement to ‘The Materia Medica’-Ordinances (Bĕn Căo Shí YíTiáo Lì, 本草拾遗·条例), Chen Cang-qi of Tang Dynasty mentioned that “there are ten types of medicinals, diffusing, unblocking, supplementing, draining, lightness, heaviness, smoothing, astringing, drying and moistening”.[6] It also listed a few medicinals underneath of each kind to elaborate theories of “diffusing to eliminate congestion”, “unblocking to remove stagnant”, “supplementing to improve feebleness”, “draining to resolve retention”, “light [herbs] to eradicate excess”, “heavy [herbs] to alleviate cowardice”, “smoothing to remove stickiness”, “astringing to fasten prolapse”, “drying to resolve dampness”, and “moistening to nourish wilting”. As we can see, the “ten types of medicinals”Chen brought up was actually from the aspect of their actions. Zhao Ji, an emperor of Song Dynasty, appended the word “preparation” behind the name of the ten types in Classic of Divine Assistance (Shèng Jì Jīng, 圣济经), such as in the chapter of Examine the Preparation (Shěn Jì Piān, 审计篇), it stated that “suppression unable to be dispersed is called congestion, and can be dissipated with diffusing preparation.”[7] In Concise Supplementary Exposition on Cold Damage (Shāng Hán Míng Lĭ Lùn, 伤寒明理论), Cheng Wu-ji declared “ten forms

of formulas that were diffusing, unblocking, supplementing, draining, light, heavy, smoothing, astringing, drying, and moistening.”[8] By then, the theory of “ten types of formulas” was explicitly brought out in formula books. However, the scope of classification based on “ten types of formulas” was not broad enough to include all types of medicinal formulas in clinical practices. Therefore, physicians of later ages added more types. For examples, Extension of the Materia Medica (Bĕn Căo Yăn Yì, 本草衍义) added cold and warm, and Miao Zhong-chun added ascending and descending. The book by Xu Si-he, Encyclopedia of Medical Professionals (Yī Jiā Quán Shū, 医家全书) added regulating, harmonizing, resolving, smoothing, cold, warm, summer, fire, neutral, depleting, calming, mitigating, bland, and clearing on top of the ten types to total up the number to twenty-four. Besides Chen Xiu-yuan of the Qing Dynasty utilized twelve of the classification methods in his book Summary Verses of Postclassical Formulas (Shí Fāng Gē Kuò, 时⽅歌括) that recorded one hundred eight formulas, not many books used these categories. Consideration of the fact that “a large number of ancient formulas were scattered disorderly and redundantly [in books] composed by different medical professionals”[9], Zhang Jing-yue of the Ming Dynasty “categorized [them] into eight classes as supplementing, harmonizing, purging, dispersing, cold, warming, consolidating, and reasoning”[10]. He then mentioned in The Complete Works of [Zhang] Jing-yuePrelude of Eight Strategies of New Formulas (Jĭng Yuè Quán Shū-Xīn Fāng Bā Lüè Yĭn, 景岳全书·新⽅八略引), “supplementing formulas [were] designated to nourish deficiencies”[11], “harmonizing formulas [were] designated to mediating disharmonies”[12], “purging formulas [were]

designated to purge excesses”[13], “[the purpose of] using dispersing ones [was] to dissipate [pathogens of] exterior patterns”[14], “cold formulas [were] designated to clear fire and eliminate heat”[15], “warming formulas [were] designated to remove coldness”[16], “consolidating formulas [were] designated to stop diarrhea”[17], and “reasoning formulas [were] designated for those that had [certain] causes. If the disease had the same manifestations, it could be treated as the same pattern. This was [how] a reasoning formula named”[18]. Zhang selected one thousand five hundred sixty-one ancient formulas; designed one hundred eighty-six new ones of his own, and classified them into the earlier mentioned eight categories in his book. Additionally, for the convenience of clinical application in specialty departments, he listed four separate categories that were for women, for children, smallpox and eruptions, and external medicine. It is obvious that the “eight categories” classification method of Zhang is the result of further improvement and development on top of the existing action-based treatment methods. In Medical Revelations Yī Xué Xīn Wù, 医学⼼悟), Cheng Zhong-ling of the Qing Dynasty declared, “in regards to medicinal formulas, they could be included into the eight methods of sweating, harmonizing, purging, dispersing, vomiting, clearing, warming and supplementing.”[19] By then, the idea of “grouping formulas based on treatment principles” was explicitly declared to summarize the theory of treatment based formula classification.

V. Comprehensive Formula Classification Wang Ang of the Qing Dynasty wrote Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ,医⽅集解), which was how the comprehensive classification method initiated. This method not only reflects the idea of grouping formulas based on treatment principles, but also takes into consideration of specialty departments. He established twenty-two classes of formulas including, supplementing and nourishing, dispersing the exterior, emesis, purging the interior, [resolving both] exterior and interior, mediating and harmonizing, rectifying qi, rectifying blood, dispelling wind, dispelling cold, clearing summer-heat, draining dampness, moistening dryness, draining fire, resolving phlegm, promoting digestion and guiding out food stagnation, astringing, killing worms, improving vision, treating abscesses and ulcers, treating menstruation and childbirth disorders, and emergency rescuing. This formula classification method was conceptually distinctive with clear grasp of clinical practice and a broad coverage, so that it was highly praised by physicians of latter generations. Some works followed the same method included Effective Use of Established Formulas (Chéng Fāng Qiè Yòng, 成⽅切⽤) written by Wu Yi-luo, and Convenient Reader on Established Formulas (Chéng Fāng Biàn Dú, 成⽅便读) by Zhang Bingcheng, both lived in Qing Dynasty. In conclusion, medical professionals along history had different definitions, some simpler than others, in terms of formula classification. There were countless formula books and effective formulas that have accumulated from the ancient ages to the modern era. Furthermore, one

formula may have multiple applications and involve multiple treatment methods. There is still much work to be done to make the classification specific, yet not convoluted and simple enough, yet not too general or with omissions. This book follows the rule, “grouping formulas based on treatment principles” with its classification according to actions and treatment methods convenient for teaching and clinical practices. Each chapter in part two of the book discusses a specific class of formulas with a total of eighteen categories. They are exterior releasing, purging, harmonizing, heat clearing and summerheat dispelling, internal warming, supplementing and boosting, astringent consolidating, spirit calming, orifice opening, qi rectifying, blood rectifying, wind expelling, dryness dispelling, dampness resolving, phlegm resolving, promoting digestion to guide out stagnant food, worm expelling, and vomiting. If a chapter contains a large body of content, it will be divided into a few sections. This way, we can make the best effort to maintain the uniformity of the formulas and corresponding treatment methods with accurate concepts and in proper order by adding clear outlines and subtitles. We hope it makes it easier for the readers to learn and master, so that it sets a great foundation in pattern differentiation, formula determination and medicinal composition for the future.

Endnotes: [1] 君⼀臣⼆，制之⼩也。君⼀臣三佐五，制之中也。君⼀臣三佐 九，制之⼤也 [2] 君⼀臣⼆，奇之制也。君⼆臣四，偶之制也。君⼆臣三，奇之 制也。君⼆臣六，偶之制也 [3] 补上治上制以缓，补下治下制以急，急则⽓味厚，缓则⽓味薄 [4] 近⽽奇偶，制⼩其服，远⽽奇偶，制⼤其服。⼤则数少，⼩则 数多，多则九之，少则⼆之。奇之不去则偶之，是谓重⽅ [5] 制⽅之⽤，⼤、⼩、缓、急、奇、偶、复七⽅是也 [6] 药有宣、通、补、泄、轻、重、滑、涩、燥、湿⼗种 [7] 故郁⽽不散为壅，以宣剂散之 [8] 制⽅之体，宣、通、补、泄、轻、重、滑、涩、燥、湿⼗剂是 也 [9] 古⽅之散列于诸家者，既多且杂，或互见于各门，或彼此重复 [10] 类为八阵，曰补、和、攻、散、寒、热、固、因 [11] 补⽅之制，补其虚也 [12] 和⽅之制，和其不和者也 [13] 攻⽅之制，攻其实也 [14] ⽤散者，散表证也 [15] 寒⽅之制，为清⽕也，为除热也 [16] 热⽅之制，为除寒也

[17] 固⽅之制，固其泄也 [18] 因⽅之制，因其可因者也。凡病有相同者，皆可按证⽽⽤ 之，是谓因⽅ [19] 论治病之⽅，则又以汗、和、下、消、吐、清、温、补八法 尽之

CHAPTER 4 Composition of Formulas The majority of the formulas used in Chinese medicine clinical practice contain multimedicinals. Following pattern differentiation based, root-cause analysis and determination of the treatment method, comes the stage of specific formula composition and medicinal selection. It is very important to emphasize a couple of key components, vigorous fundamental structure of the formula and proficient medicinal combination techniques.

Section 1 Goals of Medicinal Combination in Chinese Formulation Each medicinal has its own pros and cons. With reasonable organization, the negative attributes of each medicinal is regulated by subduing or altering their adverse actions or consolidating the desired actions. Consequently, factors that are harmful to the human body are either eliminated or alleviated. This helps bring about the comprehensive functions of mutual enhancement or complementing with opposing properties. Thereby, the formula as a whole fits the requirement of treatment based upon pattern differentiation. The process of teaming up medicinals properly is named pèi wǔ (combination of medicinal, 配伍). Pèi means organize or match while wǔ literally means an ordered group or team.

Xu Ling-tai said that “[a] medicinal has its own specialized signature, [while a] formula offers exquisite medicinal applications as a combined group”[1], and “a formula and a medicinal ingredient may seem like they are the same but, actually they are not. [A medicinal] absorbs the qi between heaven and earth manifesting its unique traits and actions [such as] altering qi flow or the status of blood for treating diseases. This is the power of a medicinal. On the other hand, the characteristics of plants are different from the human body. When they enter the stomach and bowels, how can it deliver the medicinal effects that people expect? [It is because] the sages regulated every medicinal within the formulas they created. Some medicinals are used to purge, some are there to heal, some promote each other, some supplement the other with an opposing trait, some dependent upon one another, and some subdue another. Therefore, a sophisticated formula ensures that the medicinals function to their fullest extent while making other unwanted properties disappear. The great power of having [all of the medicinals] under control is the excellence of a formula (Treatise on the Origin and Development of Medicine-Discussion on Variance and Unity of Formula and Medicinals, Yī Xué Yuán Liú Lùn-Fāng Yào Lí Hé Lùn, 医 学源流论·⽅药离合论)”[2]. In this paragraph, Xu Ling-tai addressed the importance of appropriate medicinal combination in composing a formula. We all know that each single medicinal may have multiple actions. To treat disease, we need it to exert a partial, desired function. Concurrently, while a medicinal has its medicinal effect, it also has its adverse or poisonous effects due to its nature. One needs to be familiar with the medicinal actions as well as the adverse or poisonous effects of each medicinal in order to further master the course of treatment and the methods used to control unwanted effects, as well as, practical techniques. Chinese medical professionals in the past and present have accumulated an

enormous amount of knowledge of those methods and techniques through both the development of theory and the experience from their clinical practice. Therefore, it is very important to make a thorough, comprehensive study and master the correct techniques regarding the combination of medicinals. This ensures the proper use of the medicinals that compose formulas as well as to promote flexible applications. This is also important to reduce the arbitrary use of formulas and medicinals so that clinical efficacy can improve. Generally speaking, the main objectives of the combination principles while composing a formula are to enhance the treatment efficacy and to attenuate poisons. “The use of [a single] medicinal has advantages as well as drawbacks; while there are only advantages when using a formula.” Therefore, the fundamental goal of Chinese medicinal formulation is to promote the merits of the medicinals ability to treat diseases while controlling, reducing, and even eliminating their undesirable effects on the human body. In general, by combining medicinal materials the following results can be obtained:

1. Enhancing the medicinal power The simultaneous use of medicinals with similar actions can enhance certain treatment effects. This is one of the most commonly used combination method in practice. For examples, jīng jiè combines with fáng fēng to scatter wind and release the exterior, bò he and tea leaves clear pathogens from the head and eyes, dăng shēn and huáng qí supplement the spleen and boost qi, and táo rèn and hóng huā invigorate blood and dispel stasis.

2. Promoting synergetic actions

Some medicinals need to work in coordination with another to achieve certain treatment effects. For example, má huáng and guì zhī combine to “open interstitial spaces” and “release the flesh”. In combination there is a synergy that is stronger than when using má huáng or guì zhī alone. Fù zĭ combines with gān jiāng because, as the famous adage says, “without [gān] jiāng, fù zĭ cannot heat up”[3], to simultaneously warm the innate kidney yang and postnatal spleen yang. By coordinating the “migrating without guarding”[4] property of fù zĭ and the “guarding without migration”[5] property of gān jiāng, the yang-warming and cold-dispelling action of both can be improved to a much greater level.

3. Regulating multi-functional medicinals to exert desired actions This is another important aspect among the principles of medicinal combination. For example, guì zhī has many functions including releasing exterior to dispel cold, regulating ying and wei qi, warming channels to relieve pain, warming yang to transform qi, and calming surging and directing counter flow downward. However, the exertion of a desired specific function of guì zhī within a multi medicinal formula is controlled by a number of factors, including medicinal combination. As mentioned in the previous paragraph, it combines with má huáng to induce sweat and release the exterior. It is teamed up with xì xīn to warm the channels and cease pain. It combines with sháo yào to harmonize ying and wei, as well as, yin and yang. It mixes with fú líng and gān căo to calm surging and direct counter flow down. When we need its function to warm the channels and invigorate blood, we usually combine it with mŭ dān pí and chì sháo. If the desired function from guì zhī is to warm yang and transform qi, then combine it with fú líng and bái zhú.

Take huáng băi as another example. Its functions include clearing heat to drain fire, clearing heat and transforming dampness, and clearing deficiency heat to bear down vacuity fire. At the same time, these functions can only be exerted when used in combination with huáng qín, huáng lián, cāng zhú, and zhī mŭ respectively. Let’s also take a glance at chuān xiōng. It is capable of dispelling wind to stop pain, invigorating the blood, and moving qi. The first ability can be achieved by combining it with channel envoy medicinals such as qiāng huó, xì xīn, and bái zhĭ. The second function can be reinforced if it is combined with dāng guī and sháo yào. In order to move qi and resolve constraint, chuān xiōng needs to be combined with xiāng fù or cāng zhú. Finally, chái hú is able to soothe the liver to rectify qi, raise the yang and lift qi, and disperse the exterior to eliminate heat. However, it must be combined with sháo yào to soothe the liver, shēng má to raise yang, and huáng qín to harmonize shaoyang. It is easy to conclude from these examples that the desired function of a medicinal can be directed through proper combination. In this way, the arbitrary use of medicinals in a formula can be reduced in clinical practices.

4. Expending the scope of application to accommodate sophisticated disease conditions During the long history of development, Chinese medicine has gone through repeated practice concluded by physicians in different eras, resulting in a lot of formulas underlying basic disease mechanism, such as Sì Jūn Zĭ Tāng (Four Gentlemen Decoction), Sì Wù Tāng (Four Substances Decoction), Èr Chén Tāng, Píng Wèi Săn (Stomach-Calming Powder), and Sì Nì Săn (Frigid Extremities Powder). The treatment range of these base formulas can expand through specific combination method according to pattern differentiation.

For instance, Sì Jūn Zĭ Tāng can boost qi and strengthen the spleen. Thus, it is mainly indicated for spleen and stomach qi deficiency with symptoms of poor appetite, loose stools, yellowish and gloomy facial complexion, low voice, shortness of breath, fatigue, lack of strength, and a soft, forceless pulse. If spleen deficiency causes dampness which then blocks qi flow and results in chest and abdominal stuffiness, then chén pí can be added to form Yì Gōng Săn (Special Achievement Powder). It boosts qi and enhances the spleen and moves qi to resolve stagnation. If spleen deficiency leads to phlegm-dampness stagnation causing nausea, vomiting, chest and abdominal distention, cough, and an excessive thin white phlegm, then bàn xià should be added to make it Liù Jūn Zĭ Tāng (Six Gentlemen Decoction). It focuses on supplementing spleen qi to transform phlegm-dampness. If the condition of qi stagnation due to heavy phlegm occurs in a concurrent pattern of spleen and stomach qi deficiency to cause poor appetite, belching, abdominal distention or pain, vomiting, and diarrhea, mù xiāng and shā rén need to be combined to make Xiāng Shā Liù Jūn Zĭ Tāng (Costusroot and Amomum Six Gentlemen Decoction). It fortifies the spleen, harmonizes the stomach, moves qi, and transforms phlegm. As we can see, the ability to expand the scope of treatment can be constantly achieved by combining other medicinals according to the disease pattern.

5. Controlling the side and poisonous effects of medicinals “All medicine is somewhat toxic.”[6] Information from Chinese medical history reveals that in ancient times, people were utterly afraid of the adverse and poisonous effects caused by medicinals and referred them as “poisons”. There was the mythological story, “Shen Nong tasted hundreds of herbs and encountered seventy adverse reactions in a day”[7]

and the legend of “if a medicine causes dizziness and vertigo, then the inveterate disease cannot be fully cured”[8]. There were also records of the official in feudal times sampling medicines for the king, or the son sampling them for his father. This tells us that, in general, the use of medicinals can produce side effects. However, with the advancement of Chinese medicine and the accumulation of experience regarding the use of medicinals, especially in formulation, medical professionals, through continuous exploration, mastered the methods to control adverse and toxic effects. This sets the foundation for future generations to expand the use of medicinal formulas and improve their efficacy. Up until the late Western Han Dynasty, the appellation of Chinese medicine was changed from “poisons” to “medicinals”, which itself was a landmark sign of the progress in Chinese medicine. This achievement was inseparable with applications of medicinal combinations and compatibility rules. The control of adverse and poisonous effects through appropriate medicinal combination is primarily reflected by two aspects. First, the “mutual suppression” and “mutual restraining”relationships, among the “seven relations”, are applied while using one medicinal to reduce the toxic or side effects of another. For example, shēng jiāng can reduce and eliminate the toxicity of bàn xià and shā rén can reduce the overly rich shú dì huáng from obstructing the spleen. Second, when we use certain multiple medicinals with similar functions concurrently, it not only takes the advantage of the synergy created among them, but also effectively reduces the toxic or side effects. This is because when medicinals of similar function are used simultaneously, the quantity of each is decreased and the directions of their side effects are often inconsistent. According to the principle of toxicity sympathizing with that of the same nature and

restraining with that of the opposite nature, treatment efficacy can be warranted with maximum control while abating adverse and poisonous effects. For example, gān suì, yuán huā, and jīng dà jĭ in Shí Zăo Tāng have the similar effect of expelling water through purgation. Also, the habitual dosage of each is also similar. They are used as powders of equal weight to compose Shí Zăo Tāng and taken with dà zăo decoction. The total quantity of the three herbs combined is equivalent to the common dosage of a single medicinal. Modern animal experiments and clinical observations have proven that these particular combination methods can ease and reduce adverse and toxic effects. It should be noted that besides the above two aspects, there is a wealth of knowledge about controlling adverse side effects and poisons in Chinese medicine. Examples include: the three considerations of time, person, and place, proper and aptly controlling the dosage, specific processing methods, selecting genuine regional medicinals, the particular decoction or administration methods, and the appropriate preparation methods.

Section 2 Basic Structures of Formula Composition In order to properly compose a formula, one must first analyze the condition of the disease, differentiate the pattern, select the proper treatment method(s), and then finally determine the formula. The organization of the medicinals, in terms of their roles, within the formula should coincide with the fundamental formula structuring rules. Namely, they should follow the rules of “chief, deputy, assistant, and envoy”. Following this method best reflects the master-follower, mutual reinforcement, and restraining relationships of the medicinals. It ensures that the entire formula is balanced well and that the primary medicinals are distinct versus the secondary medicinals. It makes the best use of the formula’s strength and helps to bypass its weakness in order to achieve the goal of improved clinical efficacy. The theory of chief, deputy, assistant, and envoy in Chinese formulation originated in Basic Question-Grand Discussion of Most Important Truth and Essentials (Sù Wèn-Zhì Zhēn Yào Dà Lùn,素问·至真 要⼤论). It states that “[the medicinal designated for] the primary disease is the chief, [the one that] assists the chief is the deputy, [the one that] associates with the deputy is the envoy”.[9] Later, Zhang Yuan-su of the Jin State claimed that “the chief has larger force”.[10] Therefore his classification was based on the medicinal power. Certainly, there were physicians who made this distinction based on the dosage.

Li Dong-yuan said: “[The one targeting] the main disease is the chief. The accompanied symptoms are taken care of by the respective assistant and envoy medicinals. These are the essential [rules] for creating formulas.”[11] Also, “the chief has a heavier weight, followed by the deputy. The assistant(s) and envoy(s) are even less. The weight of the deputy cannot surpass the chief. [Only when] the chief and deputy are in order, arranged to promote and restrain each other, can one resist pathogens and eliminate disease.”[12] He Bo-zhai of the Ming Dynasty, on the other hand, addressed that the “chief, deputy, assistant and envoy” were determined based on whether their effect was aimed at the major symptoms or the minor ones. He said: “Generally, medicinals used to treat diseases all serve a primary purpose. The medicinal indicated for the major treatment goal is the chief. The auxiliary medicinal is the deputy. The medicinal assisting the chief, with its opposite property, is the assistant. The medicinal that guides the effect of the other medicinals to the disease location is the envoy.”[13] Whether it is described in The Yellow Emperor’s Inner Classic, or by physicians such as Zhang Yuan-su, Li Dong-yuan, and He Bo-zhai there have been explanations of “chief, deputy, assistant, and envoy”. While their definition was neither systematic nor comprehensive, they at least provided a description to some extent. Based upon the elaborations of various scholars and the composition rules of famous formulas throughout history, we have made following summaries: Chief medicinals: The medicinals aimed to treat the major disease or pattern. Deputy medicinals: There are two types:

● Supporting medicinals that enhance the treatment effects on the major disease or pattern;

● Medicinals that target a secondary major disease or pattern. Assistant medicinals: There are three types:

● Adjuvant agents: coordinate with the chief and deputy to enhance the treatment effects, or direct treatment to a minor secondary pattern;

● Restricting agents: reduce or eliminate the toxic effect(s) of the chief and deputy, or restrain their fierce nature;

● Opposing adjuvant agents: aid the chief with an opposite property and flavor. They serve a complementary role in the treatment when the body has a repelling action towards the medicine due to the severity of the disease and pathogenic factors. Envoy medicinals: There are two types:

● Channel envoy: guide the effect of the other medicinals to a designated channel;

● Mediator: reconcile and harmonize the effects of the other medicinals. The above elucidation shows that the chief, deputy, assistant, and envoy in a formula are determined based on their roles, either major or minor. Unlike the chief, the other three categories all have two or more types. It is not mandatory to include all four roles all of the time when selecting medicinals or composing a formula, nor is it mandatory that an ingredient serves only one role. It is rather dependent upon the disease condition to determine whether or not all four categories are required. Therefore, it is subordinate to the theoretic principles.

The chief medicinal(s) or those that are indispensable are typically fewer in number than the other medicinals in a formula. They also make up a larger quantity than the other medicinals, with the quantity at the upper range of the common dosage. This is a basic fundamental requirement of formula composition. In larger formulas with many medicinals or in compounds consisting of multiple formulas, we only need to analyze the medicinals based on their actions in order to distinguish the major and minor roles. To further illustrate the specific application of the chief, deputy, assistant and envoy theory, we will use Má Huáng Tāng (Ephedra Decoction) as an example. Má Huáng Tāng (Ephedra Decoction) was first recorded in Treatise on Cold Damage. It is indicated for an excess pattern of externally contracted wind-cold. The symptoms of this pattern include aversion to cold, fever, headache, body aches, no sweat, and panting. The tongue coating is thin and white. The pulse is superficial and tight. The disease mechanism is the result of exogenous cold invading the exterior of the body, obstructing the wei-yang, constraining the ying-yin, and blocking the lung qi from dispersing. The treatment method is to induce sweating with acrid-warm medicinals that release the exterior, diffuse the lung, and calm labored breathing. The composition of Má Huáng Tāng (Ephedra Decoction) is as follows:

● Chief-má huáng: ○ acrid and warm ○ induces sweat and releases the exterior to expel wind-cold ○ diffuses the lung to calm labored breathing and counter flow qi ● Deputy-guì zhī:

○ acrid, warm and sweet ○ releases the flesh to enhance má huáng’s action of inducing a sweat to dispel cold

○ unblocks the vessels with warmth to relieve headache and body aches

● Assistant-xìng rén: ○ bitter and neutral ○ descends the lung qi and assists má huáng to calm labored breathing ○ an adjuvant agent to má huáng ● Envoy-zhì gān căo: ○ sweet and warm ○ harmonizes the other medicinals By analyzing Má Huáng Tāng (Ephedra Decoction), we now understand both the rationality of the medicinal combination in response to the disease mechanism and the organizational structure of the medicinals within the formula selected to serve major or minor targeted roles. In this manner, the formula may be designed as a balanced composition that addresses the overall disease situation of the patient in order to better exert the desired holistic effect. In sum, a precise formula design requires the thorough use of Chinese medicine theory. To “write a prescription according to the treatment principle” is the principle of medicinal selection for formula composition. It ensures the pertinence of a prescription to the disease mechanism held in line with the general premise of the disease condition. The “chief, deputy, assistant and envoy” theory describes the basic formula structure and form. It reflects and

organizes the treatment principle to warrant treatment efficacy. One can compose a greatly effective formula through the correct understanding of the above along with a sophisticated skill in medicinal selection and combination.

Section 3 Modifications in Formula Composition Formula composition follows strict principles yet allows for a great deal of flexibility at the same time. During the clinical use of established formulas we should be flexible in their application. It is important to consider the physical constitution of patients, their age group, the seasonal climate, natural conditions, soil differences, and changes in disease conditions. Only by uniting principles with flexibility in specific practices, can the intended purpose be sufficiently achieved and accomplished what is referred to as “obeying the rules but not being trammeled by the formula, referencing the formula but not restrained by the medicinals”[14]. As Xu Ling-tai addressed, “if [you] want to use an ancient formula, [you] must first review whether the patient’s disease condition matches the [indicated] pattern, and then use it. Otherwise, [you] have to make additions and subtractions; if there is no way to add or subtract, then choose another one (Treatise on the Origin and Development of Medicine-Discussion of Mastering Formulas in Treating Diseases, Yī Xué Yuán Liú Lùn-Zhí Fāng Zhì Bìng Lùn, 医学源流论·执⽅治病论).”[15] It explained that we should not be confined to the established formulas but rather alter them with flexibility according to the needs of a specific disease condition. The types of formula modifications are explained in the following paragraphs.

1. Additions and subtractions of medicinals A formula is composed with different medicinals that in turn are the main factors determining the actions of the formula. When medicinals are

added or subtracted from the formula, the compatibility relations will change, leading to the alteration of its actions. These modifications are mainly for the clinical use of established formulas which aim to make them more suitable for the various conditions of the patients. It must be noted that this modification refers to the addition or subtraction of less important medicinals. The main disease, primary pattern, basic disease mechanism, and chief medicinals remain unchanged. These adaptations made to match the evolved condition of patient are what is often called “addition and subtraction according to the pattern”. For example, Sì Jūn Zĭ Tāng (Four Gentlemen Decoction) consists of rén shēn, bái zhú, fú líng, and gān căo. It has the actions of boosting qi and fortifying the spleen. It is indicated for spleen and stomach qi deficiency, with a pallor facial complexion, poor appetite, shortness of breath, fatigue, pale tongue, white tongue coating, and a weak pulse. In addition to the signs and symptoms of this basic pattern, if there is qi stagnation and stuffiness in the chest and abdomen, then we add chén pí to move qi and resolve stagnation (i.e., the formula is modified to Yì Gōng Săn). If the basic pattern is what Sì Jūn Zĭ Tāng (Four Gentlemen Decoction) is indicated for, plus the condition of phlegmdampness blockage with abdominal distension, vomiting, and regurgitation, we can add bàn xià and chén pí to soothe stomach and resolve dampness (i.e., the formula is modified to Liù Jūn Zĭ Tāng, Six Gentlemen Decoction, 六君⼦汤). The changes above are based on the same disease condition (stomach and spleen qi deficiency), the same sign and symptoms (pale facial complexion, poor appetite, shortness of breath, and fatigue), and the same chief ingredient (rén shēn), with modifications to the minor medicinals (the deputy and assistant, etc.) to fit the needs of the secondary conditions. Therefore, one must be aware that the indication of the selected formula,

even with modifications, remains in accordance with the disease mechanism and the main pattern; or else, the modification would be inappropriate. Another point that needs to be addressed is that the chief medicinal(s) should not be removed upon modifications. If it is, one cannot claim that the modification is version of the original formula, but rather, it is a newly constructed formula.

2. Increasing and decreasing the weight(s) of medicinals The amount of a medicinal used directly determines its strength. In some formulas, the change of the ratio of the medicinals will alter the combination relationships. This may shift the formula’s actions as well as the main aspects of its indicated pattern. For example, Sì Nì Tāng (Frigid Extremities Decoction) and Tōng Mài Sì Nì Tāng (Channel-Unblocking for Frigid Extremities Decoction) are both composed of fù zĭ, gān jiāng, and zhì gān căo. By using relatively a smaller amount of gān jiāng and fù zĭ, Sì Nì Tāng (Frigid Extremities Decoction) restores yang from desertion, and is indicated for deficient yang and excessive internal cold with signs and symptoms of cold extremities, aversion to cold, curling up while sleeping, diarrhea with undigested food, and a weak thready or deep, slow and forceless pulse. On the other hand, by including a larger amount of gān jiāng and fù zĭ, Tōng Mài Sì Nì Tāng (Channel-Unblocking for Frigid Extremities Decoction) has the action to restore yang and expel extreme yin. It unblocks the vessels to rescue it from desertion, and is indicated for the repelling of yang due to extreme yin-cold, with manifestations of extremely cold limbs, no aversion to cold, diarrhea with undigested food, and an exhausted weak pulse (Table 1). Table 1 Comparison of Sì Nì Tāng and Tōng Mài Sì Nì Tāng

Another example is Xiăo Chéng Qì Tāng (Minor Purgative Decoction) and Hòu Pò Sān Wù Tāng (Magnolia Bark Three-Ingredient Decoction), both are composed of dà huáng, zhĭ shí, and hòu pò. However, Xiăo Chéng Qì Tāng (Minor Purgative Decoction) is indicated for mild yangming bowel excess patterns with heat and feces tangled in gastrointestinal area as the disease mechanism. The treatment should be mild purgation of binding heat. The prescription contains four liang of dà huáng as the chief, three pieces of zhĭ shí as the deputy and two liang of hòu pò as the assistant. Hòu Pò Sān Wù Tāng (Magnolia Bark Three-Ingredient Decoction) is indicated for constipation with distended and painful abdomen, and its disease mechanism is qi blockage. The treatment should be to purge qi in order to promote defecation by using eight liang of hòu pò as the chief, five pieces of zhĭ shí as the deputy, and four liang of dà huáng as the assistant. The dosage ratio of hòu pò in the two formulas is one versus four. Although both use the same amount of dà huáng, there is a difference in their actual administration quantity. One dose of Xiăo Chéng Qì Tāng (Minor Purgative Decoction) is served twice while Hòu Pò Sān Wù Tāng is served three times (Table 2). Therefore, these two formulas differ in terms of their actions and indications.

From the above examples, we see that Sì Nì Tāng (Frigid Extremities Decoction) and Tōng Mài Sì Nì Tāng (Channel-Unblocking for Frigid Extremities Decoction) are indicated for the same pattern with a similar disease mechanism. However, the severity is significantly different. Only the quantities of the medicinals are different, with the essential combination relations untouched. Xiăo Chéng Qì Tāng (Minor Purgative Decoction) and Hòu Pò Sān Wù Tāng (Magnolia Bark Three-Ingredient Decoction) are indicated for different patterns and disease mechanisms so it is evident that the relationship among the medicinals has changed because of the altered dosage. We can conclude that increasing or decreasing the doses of the medicinals can either result in simple adjustments of their medicinal strength, or they may alter the medicinal relationships within the formula to change its actions, efficacy, and indication. Table 2 Comparison of Xiăo Chéng Qì Tāng and Hòu Pò Sān Wù Tāng

3. Alternate forms of preparation There are many types of Chinese medicinal preparations, each with their own characteristics. The actions and indications change as the preparation differs. For instance, Jiŭ Wèi Qiāng Huó Tāng (Nine Ingredients

Notopterygium Decoction) is often used to treat the common cold with externally contracted wind-cold-damp pattern complicated by internal heat. When the preparation is changed from a decoction to a wán (i.e., walnutsized pill), its medicinal strength is delayed yet the efficacy lasts longer so that it can treat miscellaneous internal diseases. As Wang Hao-gu praised in The Bewildering Matter (Cĭ Shì Nán Zhī, 此事难知), it would “treat miscellaneous diseases with divine effect”[16]. He further emphasized the use of “refined honey to form a wán [would be] particularly effective”. Take Lĭ Zhōng Wán (Center-Regulating Pill), indicated for spleen and stomach deficiency, as another example. When it is prepared as a decoction, the effect is fast and powerful. It is more appropriate for relatively severe conditions. However, if the situation is moderate or not urgent, one should not rush to seek efficacy but should rather prepare the formula as pills instead of a decoction for a slower and milder effect. As pointed out under its administration section in Treatise on Cold Damage, the power of Lĭ Zhōng Wán (Center-Regulating Pill), made of equal proportions of rén shēn, bái zhú, gān jiāng, and gān căo, could “not achieve that of the decoction”. In addition, there are other examples of preparing a formula as pills instead of as a decoction for moderate treatment effects. Examples include Dĭ Dāng Tāng (Resistance Decoction)-Dĭ Dāng Wán (Resistance Pill) (Table 3), and Zhĭ Zhú Tāng (Immature Bitter Orange and Atractylodes Macrocephala Decoction)-Zhĭ Zhú Wán (Immature Bitter Orange and Atractylodes Macrocephala Pill) (Table 4). In summary, there are various types of formula modifications. They include changing medicinals, changing the amounts of specific medicinals, alternate forms of preparation, and other variations. These modifications may be applied in individual circumstances or in combinations, which sometimes makes it difficult to make clear distinctions. On the other hand,

the clinical characteristics of specific applications of Chinese formulas can be thoroughly reflected only through the use of modifications. There is no other way but to master these modification methods so one can be free to handle dynamically changing disease conditions according to their wishes in order to achieve the expected therapeutic goals. Table 3 Comparison of Dĭ Dāng Tāng and Dĭ Dāng Wán

Table 4 Comparison of Zhĭ Zhú Tāng and Zhĭ Zhú Wán

Endnotes: [1] 药有个性之专长，⽅有合群之妙⽤ [2] ⽅之与药，似合⽽实离也，得天地之⽓，成⼀物之性，各有功 能，可以变易⽓⾎，以除疾病，此药之⼒也。然草⽊之性与⼈殊体， 入⼈肠胃，何以能如⼈所欲，以致其效。圣⼈为之制⽅，以调剂之， 或⽤以专攻，或⽤以兼治，或以相辅者，或以相反者，或以相⽤者， 或以相制者。故⽅之既成，能使药各全其性，亦能使药各失其性。操 纵之法，有⼤权焉，以⽅之妙也 [3] 附⼦无姜不热 [4] ⾛⽽不守 [5] 守⽽不⾛ [6] 是药三分毒 [7] 神农尝百草，⼀⽇⽽遇七⼗毒 [8] 服药不瞑眩，则厥疾不瘥 [9] 主病之谓君，佐君之谓臣，应臣之谓使 [10] ⼒⼤者为君 [11] 主病之为君，……兼见何病，则以佐使药分治之，此制⽅之 要也 [12] 君药分量最多，臣药次之，佐使药又次之，不可令臣过于 君。君臣有序，相与宣摄，则可以御邪除病矣 [13] ⼤抵药之治病，各有所主。主治者，君也。辅治者，臣也。 与君药相反⽽相助者，佐也。引经及治病之药至病所者，使也

[14] 师其法⽽不泥其⽅，师其⽅⽽不泥其药 [15] 欲⽤古⽅，必先审病者所患之证相合，然后施⽤，否则必须 加减，无可加减，则另择⼀⽅ [16] 治杂病如神

CHAPTER 5 Types of Formula Preparation After the composition of a formula is complete, it still needs to be prepared into a certain form. This is known as the preparation of formulas necessary to fit the disease condition. The preparation and composition of a formula are the two important aspects of formulation. Together, they determine the efficacy, safety, and stability of the formula. Chinese medicinal formula preparation has a long history, rich in theory and valuable practical experience. Tracing back to The Yellow Emperor’s Inner Classic, it listed decoctions, pills, powders, pastes, wines, elixirs, and other medicinal forms with a great deal of additions by later physicians. Up to the Ming Dynasty, The Grand Compendium of Materia Medica (Bĕn Căo Gāng Mù, 本草纲⽬) recorded more than forty methods of preparation. Since the founding of new China, a number of new types of preparation have been developed with the advancement of the pharmaceutical industry. They include tablets, granules, and injectable agents. The following paragraphs will briefly introduce the main features and preparation methods of commonly used preparations.

1. Decoction (tāng jì) 汤剂 The decoction was known as liquid soup (tāng yè, 汤液) in ancient times. It is prepared by soaking processed raw medicinals in alcohol or water, then boiling for a period of time, followed by filtering out the

remains to get the liquid solution. It is primarily used for oral administration of formulas such as Má Huáng Tāng (Ephedra Decoction), Xiăo Chéng Qì Tāng (Minor Purgative Decoction), and so on. Externally used decoctions are used for bathing, steaming, and rinsing the mouth. The decoction is characterized by rapid absorption, quick efficacy, and the ability to modify the formula according to the changes of disease condition. Consequently, it can address specific problems of each patient or the particularity of the differing stages of a disease comprehensively and flexibly. It is suitable for patients with relatively severe or unstable diseases. Just as Li Dongyuan stated, “Tāng means to wash away and is used for serious illnesses.”[1] The disadvantages of a decoction are that there is large quantity of solution that needs to be consumed, there is difficulty to dissolve certain active ingredients, there is the tendency to lose some active ingredients due to evaporation, they are unsuitable for large-scale production, and they are troublesome to carry.

2. Powder (săn jì) 散剂 Medicinals are mix crushed or ground evenly into a powder for internal and topical use. Orally used powder is generally ground and taken with warm, boiled water, or directly swallowed if the amount is small enough, such as with Qī Lí Săn (Seven Li Powder). There is also course medicinal powders, named “boil powder”, that can be cooked down and served as a beverage (yĭn, 饮), such as Yín Qiào Săn (Lonicera and Forsythia Powder). Powder is characterized by simple processing, relatively rapid absorption, the conservation of medicinal material, easy to take, and easy to carry. Li Dong-yuan commented: “Săn, as the metaphor for scattering, was designated for urgent illness.”[2] External medicinal powder can be made into topical patches or simply scattered over the surface of

open-wounds or lesions, such as with Jīn Huáng Săn (Golden Yellow Powder) and Shēng Jī Săn (Tissue-Generating Powder). They may also be used as ophthalmics or to be blown into the throat, and so forth, such as with Bā Băo Yăn Yào (Eight Treasure Ophthalmic) and Bīng Péng Săn (Borneol and Borax Powder). This method of preparation needs to be superfine in order to avoid irritation.

3. Pills (wán jì) 丸剂 This preparation requires one to first grind medicinals into powder or make an extract, then add agglutinant to form sphere-shaped pills. Compared to a decoction, pills are slower to absorb, have longer lasting effects, save material, are easy to take, and easy to carry. As Li Dong-yuan stated, “Wán, as the metaphor for slowness, was to treat lagging and nonurgent conditions.”[3] Therefore, pills are suitable for chronic and debilitating diseases, such as with Liù Wèi Dì Huáng Wán (Six-Ingredient Rehmannia Pill). On the other hand, there are pills with strong medicinal power which generally contain aromatics or poisonous medicinals that are not appropriate as oral decoctions. Examples include Ān Gōng Niú Huáng Wán (Peaceful Palace Bovine Bezoar Pill) and Zhōu Chē Wán (Vessel and Vehicle Pill). The most commonly used pill preparations are honey boluses, water pellets, pastry pills, and concentrated pills. A. Honey bolus (mì wán) 蜜丸 Honey boluses mix fine medicinal powder with refined honey, as a bonding agent, to make pills. They include two sizes, large and small. They have a soft, moist texture and offer mild, lasting effects with an improved flavor and tonic effect added by the honey. They are commonly used to treat

chronic and debilitating diseases and need to be taken for a long period of time. B. Water pill (shuĭ fàn wán) ⽔泛丸 Water-bonded pellets are a mix of medicinal powder with an adhesive such as cool boiled water, distilled water, wine, vinegar, diluted honey, or a medicinal solution. They are formed into small round pills that disintegrate and dissolve quickly. The absorption time is therefore shorter, so they take effect faster than a honey bolus. They are easy to swallow and are used for a variety of diseases. Examples include Yín Qiào Jiĕ Dú Wán (Honeysuckle and Forsythia Detoxicating Pill), Băo Hé Wán (Harmony-Preserving Pill), Zuŏ Jīn Wán (Left Metal Pill), and Yuè Jú Wán (Constraint-Resolving Pill). C. Pastry pills (hú wán) 糊丸 This form of pills is produced by adhering medicinal powder with the paste made of rice, wheat, or herbal leaven. They form a strong bond and have a hard texture. Therefore, they take more time to disintegrate and dissolve extending their medicinal effects when taken orally. As a result, they reduce the adverse effects of toxic medicinals and gastrointestinal irritation. Examples include Zhōu Chē Wán (Vessel and Vehicle Pill) and Hēi Xī Dān (Galenite Elixir). D. Concentrated pills (nóng suō wán) 浓缩丸 Concentrated pills are made by decocting all or part of the medicinals in a certain formula, condensing it into an extract, and combining it with fine medicinal powder. This mixture is then dried and ground and water or honey is added to form round pills. Because of its composition and small

size, it offers a higher concentration of active ingredients at lower doses. They are used to treat many kinds of diseases. Other forms of pills in this category include wax boluses, water-honey pills, mini-pills, and droplets which will not be discussed in this book.

4. Paste (gāo jì) 膏剂 First use water or vegetable oil to cook down the medicinals for a long time and then filter out the dregs for either oral or topical use. Oral preparations include liquid extracts, extracts, and decocted extracts. Topical ointments include soft and hard plasters. Most liquid extracts and extracts are blended with other agents, such as adhesives, syrups, granules, or tablets. The decocted extracts and topical ointments are explained in the following paragraphs. A. Decocted extract (jiān gāo) 煎膏 It is also known as a moist extract (gāo zī, 膏滋). It is produced by repeatedly boiling the medicinals until the solution is concentrated. Then, remove the residual materials and add refined honey or sugar to form a semi-liquid preparation. It offers a small size, high concentration, and is easy to take. It has a sweet taste with nourishing and moistening effects. It is generally appropriate for patients with chronic weakness to take for a longer period of treatment, such as with Lù Tāi Gāo (Deer Fetus Extract) and Bā Zhēn Yì Mŭ Gāo (Eight-Gem Motherwort Extract). B. Soft paste (ruăn gāo) 软膏 Soft pastes are more commonly referred to as known as ointments. They mix fine medicinal powder and proper substrate materials to make a semi-solid and condensed topical formula. Creams, part of this category,

use emulsion as the base material and can be used on the skin, mucous membranes, or the surface of wounds. Ointments have a certain viscosity that will soften, melt, and gradually be absorbed after they are smeared over the body’s exterior. It is appropriate for sores, boils, furuncles, swelling, and burns because of its lasting effect. C. Hard paste (yìng gāo) 硬膏 Also known as plaster (gāo yào, 膏药) or by its ancient name, “thin patch” (bó tiē, 薄贴). It uses vegetable oil as its substrate and fries the medicinals to certain extent. Then the residual materials are removed and it is heated up again, mixed well with medicinals and finally cooled to form a hard plaster. When needed, heat it up and spread it on a piece of cloth or paper. Then, soften it and paste it on the affected body area or acupuncture points. It can treat local and general diseases such as sores, boils, pyogenic infections, injuries from falls, fractures, contusions, strains, wind-damp Bì patterns, back pain, and abdominal pain. Commonly used hard pastes include Nuăn Qí Gāo (Navel-warming Paste) and Wàn Yìng Gāo (Panchrest Paste).

5. Alcohol tincture (jiŭ jì) 酒剂 Also known as medicinal alcohol (yào jiŭ, 药酒) or by its ancient name, sweet alcohol (jiŭ lĭ, 酒醴). One way to prepare it is by soaking the medicinals in white or yellow grain wine. Another way is to braise it by first pouring the wine with medicinals into a container. Then place the container into a cooker containing some water and boil it down. In either method, the residual materials need to be removed in order to be ready for internal or external use. Alcohol can invigorate blood, unblock collaterals, and enhance the efficacy of the other medicinals with its dispersing property.

Therefore, it is often used in wind-dispelling, collateral unblocking, and supplementing and boosting formulas such as Fēng Shī Yào Jiǔ (Wind Damp Medicinal Alcohol), Shēn Róng Jiŭ (Ginseng and Deer Velvet Medicinal Alcohol), and Wŭ Jiā Pí Jiŭ (Acanthopanax Root bark Medicinal Alcohol). In addition, topical tinctures can expel wind, invigorate blood, relieve pain, and resolve painful swelling.

6. Elixir (dān jì) 丹剂 It includes oral and topical agents. There is not a fixed form of elixir that is taken orally, as they can be pills or powder. The name elixir implies that these preparations are expensive or have drastic pharmaceutical efficacy, such as with Zhì Băo Dān (Supreme Jewel Elixir) and Huó Luò Dān (Channel-Activating Elixir). External elixirs are called by another name, dān yào (丹药). They are refined mineral medicinals placed under high temperature in order to form different shapes of crystals. They are often grinded into powder to be used to dress, wounds, treat sores, carbuncles, and deep-rooted ulcers. They can also serve as the material for producing medicated rolls, threads, and topical ointments.

7. Medicinal tea (chá jì) 茶剂 It is made by coarsely grinding medicinals and adding suitable adhesives to form a squareshaped formula preparation. To use, add boiling water or stew it to make a beverage that can be drank anytime. It is mostly used to treat colds, food accumulation, and diarrhea. Recently, there have been new medicinal tea products used for health promotion and weight-loss purposes, such as Wŭ Shí Chá (Noon Tea), Cì Wŭ Jiā Chá (Siberian Ginseng Tea), and Jiăn Féi Chá (Weight-losing Tea).

8. Distillate (lù jì) 露剂 Also known as medicated distillate (yào lù, 药露). It is usually made by distillation using fresh medicinals that contain volatile constituents in order to get a clear and aromatic solution. Generally, it can be taken as a beverage or summerheat cooling preparation. Examples include Jīn Yín Huā Lù (Honeysuckle Flower Distillate) and Qīng Hāo Lù (Sweet Wormwood Distillate).

9. Lozenge (dìng jì) 锭剂 They start with fine medicinal powder and add a proper amount of agglutinant. Form into the required shape such as spindle, cylinder, or bar for topical and oral administration. For oral use, grind it into a powder or mill in order to make it liquid. For external use, simply mill it to get the fluids and coat the surface of the skin with it. Commonly used lozenges are Zĭ Jīn Dìng (Purple Colden Pastille) and Wàn Yìng Dìng (All Curing Pastille).

10. Medicated roll (tiáo jì) 条剂 Also known as a medicated twist (yào niăn, 药捻). Mulberry bark paper with medicinal powder adhered to it is cut into thin strips. Or, the mulberry paper is twisted into a roll and the powder is then put into it. It is inserted into wounds or fistulas to remove putridity, draw out toxins, promote granulation, and heal lesions. Examples include Hóng Shēng Dān Yào Tiáo (Hongsheng Elixir Medicated Twist).

11. Medicated thread (xiàn jì) 线剂

Medicated thread is prepared by immersing, boiling, and drying silk or cotton thread in medicated liquid for topical use. It treats fistulas, hemorrhoids, or paraphytes through its mild corrosive effect and mechanical tightness that comes from the thread. It can smoothes the drainage of fistulous tracts, atrophies hemorrhoids, and eventually falls off hemorrhoids.

12. Suppository (shuān jì) 栓剂 Suppositories were known in ancient times as sitting or plugging. It is made by blending powder and substrates to create a solid preparation with a certain shape that can be inserted into the body’s cavities. When placed into the cavity, it will melt or dissolve causing it to release its medicinal constituents that offer pesticide, lubricating, or astringent effects. In Treatise on Cold Damage and Miscellaneous Diseases, there were Shé Chuáng Zĭ Săn (Cnidium Fruit Powder), a vaginal suppository, and Mì Jiān Dăo Făng (Thickened Honey Enema) for anal application; both were the earliest of its kind. This type of preparation has been developing rapidly in recent years because of its application in treating systemic diseases. It is characterized by direct rectum or vaginal mucosa absorption with fifty to seventy percent going into the general circulation without passing through the liver. It not only reduces the first pass effect of the medication, liver toxicity, and side effects, but also avoids the influence of the gastrointestinal fluids on the medicinals and irritation to gastric mucosa. Rectal administration is particularly convenient for infants and children. Some commonly used suppositories include Xiăo Ér Jiĕ Rè Shuān (Infantile Heat-Releasing Suppository) and Xiāo Zhì Shuān (Hemorrhoids-Dispersing Suppository).

13. Soluble granules (chōng jì) 冲剂

Soluble granules are prepared by blending medicinal extracts with an appropriate amount of excipients to form dry granules or powder that is ready to be mixed with boiled water. Granules taking effect quickly, have a better flavor, require a smaller dosage, and are easy to take. Therefore, they are very popular among patients. Some commonly used granules include Găn Mào Tuì Rè Chōng Jì (Common Cold and Heat-Removing Granule) and Fù Fāng Líng Jiăo Chōng Jì (Compound Formula Antelope Horn Granule).

14. Tablet (piàn jì) ⽚剂 Tablets are made by pressing the mixture of ground medicinal powders, extracts, and additives into tablets. Tablets are accurate in dosage and are small in size. Tablets with a bitter taste or strong odor can be further sugarcoated to make it easier to take. For those absorbed within the intestinal tract, they can be enteric coated. In addition, there are other forms as buccal and effervescent tablets.

15. Syrup (táng jiāng jì) 糖浆剂 Syrup is made by decocting medicinals, filtering out the residue, cooking it down to a concentrate, and adding an appropriate amount of sucrose to get a thick sugary solution. Syrup preparations are administered in small doses, are easy to take orally because they have a sweet taste, and are absorbed quickly. They are especially welcomed by children. Examples are Zhĭ Ké Táng Jiāng (Cough-Stopping Syrup) and Guì Pí Táng Jiāng (Cassia Bark Syrup).

16. Oral liquid (kŏu fú yè) ⼜服液

This oral preparation is a refined liquid that uses water or other types of solvent to extract soluble agents from medicinal materials. It incorporates the characteristics of a decoction and syrup. It is characterized by its small dosage, quick absorption, easy to take, and pleasant taste. It has been gaining more and more popularity in recent years, particularly as health promoting and tonic products, such as Rén Shēn Fēng Wáng Jiāng Kŏu Fú Yè (Ginseng Royal Jelly Oral Liquid) and Qĭ Jú Dì Huáng Kŏu Fú Yè (Lycium Berry, Chrysanthemum and Rehmannia Oral Liquid).

17. Injection agent (zhù shè yè) 注射液 There are a few steps that must be followed in order to prepare it. They include extraction, refining, and compounding in order to make a sterile solution, suspension, or solution powder for subcutaneous, intramuscular, or intravenous injection. The advantages include accurate dosing, rapid efficacy suitable for emergency cases, and it is unaffected by the digestive system. Therefore, it is especially appropriate for delirious patients that are difficult to take oral medicine. Some examples include Qīng Kāi Líng Zhù Shè Yè (Effective Clearing and Orifices-Opening Injection) and Shēng Mài Zhù Shè Yè (Pulse-Engendering Injection). Each of these preparations has its own unique characteristics and should be chosen appropriately based on their clinical use, features, and the relevant disease condition. In addition to the preparation methods illustrated above, there are also capsules, moxibustion agents, heat patches, enemas, liniments, and aerosols that are widely used clinically. Moreover, there are new formulation types continuously being developed to improve efficacy and convenience for clinical applications.

Endnotes: [1] 汤者荡也，去⼤病⽤之 [2] 散者散也，去急病⽤之 [3] 丸者缓也，舒缓⽽治之也

CHAPTER 6 Administration Methods The administration of a particular formula includes two aspects: timing and method. The appropriateness of administration has certain impact on the efficacy. As Dr. Xu Ling-tai of the Qing Dynasty addressed in his book Treatise on the Origin and Development of Medicine Yī Xué Yuán Liú Lùn, 医学源流论), “Whether or not a patient can recover from an illness is not only [dependant on] the formula indicated for the disease. If the formula is designated for the situation but is not taken in the correct manner, it might not be beneficial. But rather, it may be harmful. [Thus] one needs to be aware of it.”[1] Therefore, the method of administration for medicinal formulas should be emphasized. We will explain in detail according to the common practices of different historic periods.

I. Timing of the Medication Generally speaking, the appropriate time to take a medicinal formula is one hour before meals, for quick absorption. However, formulas that upset the gastro-intestinal system should be taken after meals to avoid adverse reactions. Supplementing and nourishing formulas are properly taken on an empty stomach. Formulas for malaria should be taken two hours prior to symptom onset. Those designated for calming the spirit need to be taken at bedtime. During an emergency and in severe circumstances, the

administration should be flexible. For chronic disease, one must take the formula on a regular schedule for sustainable clinical effects. Based on the status or state of the disease, there may be multiple times within a giving day for the formula to be taken. Some may be served as tea whenever the patient needs to drink water. Some unusual formulas may have very special administration methods. For example, Jī Míng Săn (Rooster’s Crow Powder) should be taken cold on an empty stomach before dawn. Experience like this can be kept in mind for reference. Our predecessors’ discussions on the administration of medicinals have also taken into account the impact of the disease locations. Whether it was in the upper or lower body, and which part it was close to. And further, whether the administration method would be suitable for removing pathogens or cultivating life. These are what should be considered clinically. For example, in Important Formulas Worth a Thousand Gold Pieces-Prelude and Guide (Qiān Jīn Yào Fāng-Xù Lì, 千⾦要⽅·序例), it states: “For a disease located above the chest and diaphragm, eat prior to taking the medicine. For that below the chest and diaphragm, take the medicine before meals. If it is on the vessels of the four limbs, it is appropriate to take [it] on an empty stomach in the morning. If it is in the bone marrow, take [it] while full in the evening.”[2] Moreover, Painstaking Formulas of Physicians (Yī Xīn Fāng, 医⼼⽅) cited Ge Hong’s remark “medicines used to treat diseases should be taken before meals; those for health cultivation should be taken after meals.”[3]

II. Medication Method A decoction is usually taken orally. One pack of medicinals is boiled twice and the decoctions are mixed and taken twice or three times each day. However, under special circumstances, two packs of medicinals may be served in only one day in order to increase the medicinal effect. Powder and pills are served twice or three times daily according to the disease condition and is based on the quantitative requirement of each medicinal. Some powder formulas can be directly swallowed with water, such as Qī Lí Săn (Seven Li Powder). Course powders can be boiled down and served as a beverage, such as Xiāng Sū Săn (Cyperus and Perilla Powder). Some are used as patches or placed directly on the wound, such as Shēng Jī Săn (Tissue-Generating Powder). Some can be applied to the eyes or blown into the throat, such as Bā Băo Yăn Yào (Eight Treasure Ophthalmic) and Bīng Péng Săn (Borneol and Borax Powder). A variety of pills can be taken with water. As for other forms, their specific preparation and functions can be referred in order to see what is appropriate. Due to a variety of different situations and experiences, our predecessors determined many empirical administration methods. As an example, a sweat-inducing and exterior-releasing formula should be served warm and, thereafter, cover the patient in order to avoid wind and promote a slight, continuous sweat for certain period of time. Cold-natured medicinals used for heat patterns can be served cold in order to help clear heat. While, those of warm property used for cold patterns can be taken warm in order to help generate heat.

However, in situations of abnormal exuberance of cold or heat, separating yin-yang, or yin-yang repulsion, the patient may have resisting phenomenon such as vomiting after taking the formula. In the case of a true cold false heat pattern, it is proper to take the warming medicinals cold. The opposite is true in patterns of true heat false cold, serve the cold medicinals warm. This is called the corrigent medication method. The same rule was recorded in Basic Questions-Grand Discussion in the Habitus of Five Qi (Sù Wèn-Wŭ Cháng Zhèng Dà Lùn, 素问·五常政⼤论). “When treating heat with cold, warmth would do; when treating cold with warmth, coolness would be good; when treating warm with coolness, coldness would do; when treating coolness with warmth, heat would be good.”[4] If a patient vomits after taking medication, give them a little ginger juice, use shēng jiāng to rub their tongue, or let them chew a little chén pí. Then after serve them the decoction, or serve it cool in multiple, small quantities doses. For unconscious patients or those who have difficulties in swallowing, nasal administration is the common method of administration used today. One should be careful and exercise caution when dispensing medicinals that have a drastic effect or are toxic by initially using a small amount with gradual increase until it is effective. Excessive use should be avoided to prevent a poisonous reaction. As Shen Nong’s Classic of the Materia Medica-Prelude and Guide (Shén Nóng Bĕn Căo Jīng-Xù Lì, 神农 本草经·序例) mentioned: “When using a poisonous medicine to treat diseases, [you should] use as little as the size of a millet initially; stop right after the disease is eliminated. Otherwise, double it; if [it is] not resolved and use ten times the initial dose, until it has subsided.”[5] This statement clearly suggested the common use of toxic medicinals. In short, the

administration method should be determined based on the disease condition and property of the medicinals during the course of the treatment.

Endnotes: [1] 病⼈之愈不愈，不但⽅必中病，⽅虽中病，⽽服之不得法，则 非特无功，⽽反有害，此不可不知也 [2] 病在胸膈以上者，先食后服药︔病在胸膈以下者，先服药后 食︔病在四肢⾎脉者，宜空腹⽽在旦︔病在骨髓者，宜满⽽在夜 [3] 服治病之药，以食前服之︔服养⽣之药，以食后服之 [4] 治热以寒，温⽽⾏之︔治寒以热，凉⽽⾏之︔治温以清，冷⽽ ⾏之︔治清以温，热⽽⾏之 [5] 若⽤毒药疗病，先起如⿉粟，病去即⽌，不去倍之，不去⼗ 之，取去为度

Supplementary Reading: Textual Research of Archaic Dosage on Medicinals By looking at the dosage of the medicinals in a formula, especially those prior to the Tang Dynasty, it was quite different compared to today. This is merely because the measuring system during various times througout history differed. In very early times, the measurements were shu (⿉), zhu (铢), liang (两), and jin (⽄), without the unit fen. As time moved toward the Jin era, measuring units included ten shu as one zhu, six zhu as one fen, four fen as one liang, and sixteen liang as one jin. Therefore, the measurement units were shu, zhu, fen, liang, and jin. It was not until the Song Dynasty that a cascading measurement system was established with the unit names of liang (两), qian (钱), fen (分), li (厘), and hao (毫). Decimal based measures were ten hao as one li, ten li as one fen, ten fen as one qian, and ten qian as one liang. Then, sixteen liang was equal to one jin. The Yuan, Ming, and Qing dynasties inherited the same system with very few changes. Therefore, the fen in formulas of the Song, Ming, or Qing periods was relevant to the above measuring unit instead of the fen equaling two and a half qian of the Jin era. The Qing made the system official and called it kù píng (exchequer level, 库平), and then changed the name to shì (market, 市). The names of archaic cubic units included hu (斛), dou (⽃), sheng (升), ge (合), and shao (spoon, 勺).The actual sizes changed from time to time. Even the results of scholastic research regarding a certain unit size differed from one another. For example, Li Shi-zhen thought that “one liang of ancient times equaled one qian of today. One sheng of ancient times was

equivalent to two and a half liang of today”. Zhang Jing-yue who lived in almost the same era during the Ming Dynasty believed that “one liang of ancient times equaled six qian of today. One sheng in ancient times is equivalent to three he and three shao of today”. The reference used below is taken from the 1960’s version of Chinese Formulation (Yào Jì Xué, 药剂学) edited by Nanjing University of Pharmacology (Table 1). Table 1 Historic Comparison of Measurements and Scales

Note: The comparative measurements are approximate values.

(Note: In reality, round up the number to the nearest decimal.)

“Equal weight”, without the specific unit in ancient formulas, means respective medicinals should weigh the same. The system is mostly used for making pills and powdered formulas rather than decoction and wine-based tinctures. There were also measuring units used for powder formulas such as fang-cun-bi (⽅⼨⼔), qian-bi (钱⼔), yi-zi (⼀字), and dao-gui (⼑圭). Fang-cun-bi was the unit of using a square-shaped mini dagger to ladle out just enough powder without spattering it, roughly equal to five fen. Qian-bi was to use a base unit coin to scoop out the powder close to three fen. A half

qian-bi was to use just half of the coin. Yi-zi, literally meant one character was using a Tang Dynasty coin with one of the four Chinese characters pressed on it to measure the powder near one fen. Dao-gui was a knife shaped jade piece that measured one tenth of a ten fen fang-cun-bi. Note that plant-based formulas are lighter than animal or mineral-based formulas. In addition, there were analogous methods for measuring formulas. As an example: one egg-yolk=one ball=forty Chinese parasol seeds=eighty soybeans=four hundred and eighty big hempseeds=one thousand four hundred and forty small hempseeds. Medical professionals in both the past and modern eras have done a lot of research regarding the weights of ancient formulas with no indisputable conclusion. What was agreed upon was that the measurements used in the Han and Jin Dynasties were definitely smaller than those of the modern era with the same unit names. Therefore, the weight of the medicinals appeared to be larger. For the purpose of comprehending the purport of compatibility rules, structural characteristics, evolutional causes, and reference ratios for clinical practices, ancient formulas are cited in their original description in modern publications. In clinical applications, we should follow the weights based on the Chinese materia medica and case studies published in modern times while considering the region, residence, age of the patient, physique of the patient, climate, and disease status. Since January 1, 1979, it became the mandatory national standard to use gram as the unit of measure for every medicinal within a Chinese medicinal formula. Hereby, the conversions from hexadecimal to standard units are as follows:

Part Two

Formula Monographs

CHAPTER 1 Exterior-Releasing Formulas Exterior-releasing formulas use exterior-releasing medicinals as major components and have the therapeutic actions to induce sweating, release the flesh, and promote eruption. The therapeutic method to release the exterior is historically referred to as the sweat-promoting method, one of the “eight medicinal treatment methods” (八法) recorded in ancient literature. Exterior patterns are caused by the six pathogenic factors and other external pathogens that invade the fleshy exterior and lung wei. They are characterized by aversion to cold, fever, headache, generalized body pain, and the presence or absence of perspiration. The tongue coating is thin and white, and the pulse is superficial. At this stage, the invading external pathogens have not penetrated into the deeper level of the body. It states in The Yellow Emperor’s Inner Classic: Basic Questions—Grand Discussion of Yin-Yang in Response to the Nature and Body (Huáng Dì Nèi Jīng Sù WènYīn Yáng Yìng Xiàng Dà Lùn, 黄帝内经素问·阴阳应象⼤论) that “for those having [been contracted with] external pathogens, soak the body [with decoction] to promote sweating; for those [with the pathogen] on the surface, induce sweating to release [the pathogens].”[1] Thus, the principle of treating

exterior patterns is to select acrid, diffusing and dispersing medicinals to release pathogens from the superficial level. If the selected treatment is inappropriate or not applied in a timely manner, the exterior pathogens will not be released from the surface but will progressively penetrate deeper and cause other disease patterns. Therefore, it is pointed out in Basic Questions —Grand Discussion of Yin-Yang in Response to the Nature and Body (Huáng Dì Nèi Jīng Sù Wèn-Yīn Yáng Yìng Xiàng Dà Lùn, 黄帝内经素问· 阴阳应象⼤论) that “a master physician starts the treatment while (the disease) is on the surface. While a practitioner of less mastery starts the treatment while it’s at the skin and muscle level, followed by the tendon and vessels level, the six fu viscera, and the five zang organs. The success rate when treating at the level of the five zang organs is about 50%.”[2] Exterior-releasing formulas are designed to address exterior patterns. Therefore, they can be applied to treat various abnormalities associated with the signs and symptoms of exterior patterns such as externally contracted wind-cold, warm diseases, measles, furuncles, external ulcers, edema, and dysentery. Exterior pathogens may be either warm or cold in nature, and the constitution of the patient may be either deficient or excess, therefore exterior patterns are further classified as exterior cold, exterior heat or exterior deficient patterns. As a result, the exterior-relieving formulas are categorized into three groups: acrid-warm, acrid-cool, and those that boost the wei qi. Exterior-releasing formulas are designated for diseases caused by the six externally-contracted pathogens. Hence the formulas that scatter and dissipate external wind, gently diffuse external dryness, and dispel wind and overcome dampness are all classified as exterior-releasing formulas. Scholars should not be too rigid about the above categories. It is only after understanding the entire context that the overall picture can be understood.

A few points must be kept in mind while prescribing exterior-releasing formulas: First, one must accurately discern the nature of the disease pattern and compose the formula appropriately. If one incorrectly uses acrid-cool medicinals to treat a wind-cold pattern, the pathogens will be trapped and become insidious, lingering and harder to cure. If one uses acrid-warm medicinals to treat a wind-heat pattern, it is like trying to extinguish a fire with wood and will only to make the heat worse. Second, the method of preparation and administration of these formulas is important when inducing a sweat aimed to release pathogens from the exterior. Due to the acrid and ascending nature of the medicinals in an exterior-releasing formula, it is inadvisable to boil it down for a long time. It will damage its original nature and reduce the efficacy of the decoction. To help induce a therapeutic sweat, it is favorable to drink the decoction warm, wear an extra layer of clothing, or cover up with a blanket to increase body warmth, and avoid exposure to wind and cold; and to supplement the decoction by consuming warm rice porridge. Raw, cold or greasy food may interfere with the absorption of the medicinal constituents therefore, avoiding them during the course of herbal treatment helps to optimize maximal treatment results. Third, it is ideal to get a slight sweat over the entire body to effectively relieve the exterior. If there is too little sweat, the pathogens will not be completely removed. On the other hand, if there is too much sweat released, it will damage the qi and body fluid. Finally, assess which aspect of the disease pattern, the exterior or the interior, has therapeutic priority. This way, the treatment plan can be formulated to epitomize the correct course of therapy. It will better guide the

treatment to progressively address the most urgent and acute symptoms and patterns as priority, as well as, address the chronic and least urgent aspects of the condition according to proper protocol. If the exterior pathogen is not completely removed, and the patient has shown signs of interior patterns, the general guideline is to relieve the exterior followed by interior. If both the exterior and interior conditions are urgent, they need to be dealt with simultaneously. Exteriorreleasing formulas are prohibited in the following scenarios: cases where the once exterior pathogen has penetrated into a deeper level; cases where measles and furuncles have completely erupted; or in cases of edema associated with a deficiency pattern.

Section 1 Acrid-Warm ExteriorReleasing Formulas Acrid-warm exterior-releasing formulas are applied to exterior windcold patterns. The signs and symptoms are aversion to cold, fever, headache, generalized body pain, presence or absence of sweating, nasal congestion, runny nose, coughing, and labored breathing. The tongue coating is thin and white. The pulse is superficial and tight, or superficial and moderate. Common medicinals found within the acrid-warm exterior-relieving formulas include má huáng, guì zhī, qiāng huó, zĭ sū yè, and fáng fēng. Binding and stagnation of ying yin is due to pathogenic cold fettering the exterior. The result is an inability of the lung to properly diffuse and descend. Consequently, the corresponding formulas often contain guì zhī and chuān xiōng to improve circulation within the blood vessels and xìng rén and jié gĕng to regulate diffusion and descent of the lung qi. Common formulas

in this category are Má Huáng Tāng, Guì Zhī Tāng, Jiŭ Wèi Qiāng Huó Tāng, Xiăo Qīng Lóng Tāng, and Xiāng Sū Săn.

Má Huáng Tāng 麻黄汤Ephedra Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Prepare Má Huáng Tāng as a decoction. The source text points out that má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals. The decoction should be taken warm and the patient should bundle up with an extra layer to induce a mild sweat.

Formula Indications Má Huáng Tāng is indicated for an externally contracted wind-cold exterior-excess pattern. The symptoms are aversion to cold, headache, generalized body pain, absence of sweating, and labored breathing. The tongue coating is thin and white, and the pulse is superficial and tight.

Analysis of Fundamental Pattern Pathogenesis This pattern is due to externally contracted wind-cold causing the lung qi to fail to diffuse. The invasion of the exterior by external wind-cold obstructs the wei yang, blocks and congests the striae and interstices, constrains ying yin, and obstructs the channels. The result is aversion to cold, fever, absence of sweating, headache, and generalized pain. The lung governs the qi and belongs to wei, which is connected with the skin and body hair at the body’s exterior. The regular diffusion and descent of lung qi is affected when the exterior of the body is restrained by wind-cold. The body’s exterior is linked internally with the lung. Therefore, the tension of the body’s exterior constrains the lung qi within. The constrained lung qi ascends counterflow to induce labored breathing. Thin and white tongue coating and a superficial, tight pulse are indications of an exterior fettered by wind-cold. The treatment is to induce sweating to release the exterior and diffuse the lung to calm labored breathing.

Formula Actions Induces sweating to release the exterior; diffuses the lung to calm labored breathing.

Formula Analysis

Continued

Unique Combination Features Má huáng and guì zhī mutually reinforce one another to diffuse wei qi bound at the exterior due to an external cold pathogen; open up blocked striae and interstices; and remove the constraint at the ying level. Given this synergism, the sweat-inducing and exterior-releasing actions have an obvious effect. At the same time, má huáng and xìng rén mutually assist each other to resolve disturbed diffusion and descent of lung qi. All together, they yield a remarkable effect to diffuse the lung and calm labored breathing.

Further Clarification Regarding the combination of má huáng and xìng rén: the lung governs the diffusion, dispersion, purification and descent of qi. When excessive pathogenic qi blocks its pathway, the lung loses control to cause coughing and labored breathing. Má huáng is great to diffuse the lung qi and stop coughing and calm labored breathing. The interaction of diffusion and descent within the lung system needs to be in dynamic balance; therefore xìng rén is often combined with má huáng in clinical practice.

Formula Applications 1. Essential pattern differentiation

Má Huáng Tāng is used to treat an externally contracted wind-cold exterior-excess pattern. It is both a fundamental and a representative formula. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of an exterior-excess wind-cold pattern: common cold, flu, upper respiratory tract infection, acute bronchitis, bronchial asthma, and rhinitis. 4. Cautions and contraindications To avoid qi consumption and fluid damage, this formula should not be overdosed because of its drastic sweat-inducing effect. It is not applicable for patients with patterns such as exterior-deficiency wind-cold, exterior wind-heat, and exterior wind-cold with a weak constitution.

Associated Formulas

Má Huáng Jiā Zhú Tāng (Ephedra Decoction Plus White Atractylodes, 麻黄加术汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals. The decoction should be taken warm and the patient should bundle up with an extra layer to induce a mild sweat. [Actions] Induces sweat to release the exterior, disperses cold and removes dampness. [Applicable Patterns] Exterior wind-cold complicated by damp bì syndrome. Symptoms include: generalized aches and irritability, aversion to cold, absence of sweating, a thin and white tongue coating and a superficial pulse. Má Huáng Xìng Rén Yì Yĭ Gān Căo Tāng (Ephedra, Apricot Kernel, Coix and Licorice Decoction, 麻黄杏仁薏苡⽢草汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. The decoction should be taken warm. [Actions] Induces sweat to release the exterior, dispels wind and eliminates dampness [Applicable Patterns] Exterior wind-dampness complicated by constrained dampness transforming to heat. Symptoms include:generalized body pain, fever that worsens in the afternoon, absence of sweating, a thin and white tongue coating and a superficial pulse. Dà Qīng Lóng Tāng (Major Green Dragon Decoction, ⼤青龙汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals. The decoction should be taken warm and the patient should bundle up with an extra layer to induce a mild sweat.

[Actions] Induces sweat to release the exterior, clears internal heat [Applicable Patterns] Externally contracted wind-cold with depressed internal heat. Symptoms include: aversion to cold, fever, headache, body aches, absence of sweating, vexation and agitation, thirst, and a superficial and tight pulse. Sān Ào Tāng (Rough and Ready Three Decoction, 三拗汤) [Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Grind to rough powder and use 5 qian (15 g) per intake. Add 5 pieces of shēng jiāng upon boiling. [Actions] Diffuses the lung to release the exterior. [Applicable Patterns] Externally contracted wind-cold with lung qi failing to diffuse. Symptoms include: nasal congestion, deep, harsh or loss of voice, and cough and chest oppression. Huá Gài Săn (Florid Canopy Powder, 华盖散)

[Source] Extensive Relieving Formulas (Bó Jì Fāng, 博济⽅) [Ingredients]

[Preparation and Administration] Grind to powder and use 2 qian (6 g) per dose. [Actions] Diffuses the lung to release the exterior, dispels phlegm and relieves cough. [Applicable Patterns] Phlegm-excessive constitution with external wind-cold attacking the lung. Symptoms include: cough with white phlegm, oppression and fullness in the chest and diaphragm area, nasal congestion, harsh voice, aversion to cold, fever, a white and moist coating, and a superficial and tight pulse. These five formulas are all modified from Má Huáng Tāng. Both Má Huáng Jiā Zhú Tāng and Má Huáng Xìng Rén Yì Yĭ Gān Căo Tāng are indicated for externally contracted wind-cold patterns complicated by dampness. However, the former treats patients with an excessive damp constitution complicated by external wind-cold invasion that have more severe signs of external cold and body pain than the latter. Má huáng and bái zhú are combined to induce sweating, release the exterior, expel cold and remove dampness. The latter formula’s pattern exhibits less severe external cold and body pain, but there is a fever that worsens in the afternoon—an

indication of dampness being transformed to heat. Thus, by removing guì zhī and adding dampness-draining yì yĭ rén, it gently clears, diffuses and transforms the pathogen to release the exterior and resolve the dampness. A small dose of this formula is suggested to induce mild sweating. Dà Qīng Lóng Tāng is composed of Má Huáng Tāng with extra má huáng, plus shí gāo, shēng jiāng and dà zăo. It is designated for a more severe external excess wind-cold pattern complicated by constrained internal heat. It uses a larger amount of má huáng for a stronger sweat-inducing effect. Vexation and agitation in this pattern is caused by agitated internal heat. Adding shí gāo clears the heat to resolve irritability. Shēng jiāng assists má huáng and guì zhī to dispel the exterior pathogens. Dà zăo and gān căo benefit the spleen and stomach to nourish the source of sweat. Once there is sweating, the surface is relieved of the cold pathogen, and the heat and irritability are eliminated. Sān Ào Tāng and Huá Gài Săn are both modified from Má Huáng Tāng by removing guì zhī for a lighter sweat-inducing effect and to place more emphasis on dispersing the wind-cold pathogen that has penetrated the lung. They are indicated for the pattern of external wind-cold invading the lung causing cough and labored breathing. Sān Ào Tāng is a basic formula used to release the exterior and diffuse the lung and is therefore indicated for a pattern with mild coughing and labored breathing. On the other hand, Huá Gài Săn is applicable when a person with an excessive phlegm constitution is afflicted by wind-cold attacking the lung. It adds zĭ sū zĭ, chén pí, sāng bái pí, and chì fú líng to Má Huáng Tāng to descend qi and remove phlegm and enhance the actions of eliminating cough and calming labored breathing.

Case Studies 1. Loss of voice due to cold blockage

Wang Zhi-chang, professional duck breeder. Every day during the cold and windy season of late-winter, he herds ducks out on the open roadways. There, exhausted, he gets exposed to a mix of snow and rain. One night when he got home, he felt uncomfortable and drank a large cup of cold tea. By midnight, he developed an aversion to cold, a fever, and a cough with a deep, hoarse voice. Shortly after, he lost his voice. He took several cups of ginger decoction with cedar charcoal, yet his voice remained deep and hoarse. Unable to speak properly, his father described the circumstances on his behalf. Mr. Wang suffered general body pain, with absence of sweating, had no tongue coating, and his pulse was superficial and tight indicating an exterior excess pattern of the taiyang channel. It was concluded that he had cold invading the lung obstructing the upper orifices causing the cough and loss of voice. The loss of voice was because of the damage of the lung due to external cold compounded by the consumption of a cold drink. This caused the lung to be muffled and unable to produce sound. It was decided that the appropriate treatment was to open the pores and diffuse lung qi. He was prescribed Má Huáng Tāng composed of má huáng 9 g, guì zhī 6 g, xìng rén 6 g, and gān căo 3 g. After taking the decoction, the patient covered up with an extra blanket to help induce sweating. He had to change out of wet clothes twice. The next day he was relieved from the external pathogenic condition. His voice had slightly improved; however, he still had phlegm while coughing and mild distending pain in the chest. He was prescribed a modified Má Huáng Tāng by subtracting guì zhī, reducing má huáng to 4.5 g, and adding bèi mŭ 6 g, jié gěng 6 g, bái dòu kòu 3 g, and xì xīn 1.5 g so the formula will warm the lung and resolve phlegm. After he took two doses the coughing stopped and his voice became normal.1

Comments: Through inquiry and pulse diagnosis, it was understood how the patient became ill. The patient had a typical external excess windcold pattern. Thus, Má Huáng Tāng was exactly the right formula. After eliminating the exterior symptoms, the prescription was altered by removing guì zhī, decreasing má huáng, and adding bèi mŭ, jié gěng, bái dòu kòu, and xì xìn. The lung-moistening, phlegm-resolving and throat-comforting medicinals assisted the acrid-opening medicinals in this formulation to further prevent the cold pathogen from being constrained for too long and its transformation into heat. 2. Allergic rhinitis 1 Zhao Shou-zhen. Memoirs of Effective Treatment 治验回忆录. Beijing: People’s Medical Publishing House; 1963. p. 12-13.

Zhang, male, 61 years old. Three years ago he suffered from a cold with nasal congestion and runny nose. He went to the hospital and was diagnosed with allergic rhinitis. Medications such as antibiotics, Naphazoline and nasal decongestants were initially effective for him, however, for nearly a year now his condition could only be minimally controlled, and only with oral Prednisone. However they would reoccur quickly once he stopped taking it. His signs and symptoms included a pale facial complexion, nasal congestion with clear nasal mucus, absence of phlegm, and itchy ears, nose, lips and throat that worsens when it turns cold. His tongue was pale with a white and moist coating, and his pulse was wiry and tight. The pattern was diagnosed as an invasion of the lung by wind-cold causing obstruction of the nasal cavity. Therefore the appropriate treatment was to dispel wind, dissipate cold, diffuse the lung and free the nasal cavities. He was prescribed: má huáng 6 g, guì zhī 15 g, zhì gān căo 10 g, xìng rén 15 g, fáng fēng 15 g, quán xiē 6 g, and wú gōng 2 pieces. Second visit: After taking three doses of the medicine, his nasal cavities were free, his itchiness was alleviated, and

he was able to stop taking Prednisone. After he took another 6 doses the symptoms were all eliminated. His case was followed for eight months without any reoccurrence noted.1 Comments: The nose is the opening of the lung. Nasal congestion with runny, clear snivel results from wind-cold attacking the lung and obstructing its pathways. Therefore, one cannot only treat the nose, but must also treat the lung. Itchiness that affects various body regions indicates wind pathology. Therefore in the case above, Má Huáng Tāng was used to diffuse the lung, dissipate cold, and unblock the nasal cavities. Fáng fēng, quán xiē, and wú gōng were used to dispel wind, track down pathogens and stop itchiness.

Guì Zhī Tāng 桂枝汤 Cinnamon Twig Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Guì Zhī Tāng is prepared as a decoction. Compliance with the exact instructions for taking this formula is very important to achieve the desired therapeutic effect. It should be taken while it is warm. Following consumption of the warm decoction, the patient needs to additionally consume a bowl of warm rice porridge. The grain qi of the rice enhances the strength of the medicinals and boosts the stomach qi to help expel cold pathogens. Thereafter, the patient should either put on warm clothes or bundle up in a blanket to help induce a light sweat. The reason for this is to avoid further wind invasions and to promote sweating.

Formula Indications Guì Zhī Tāng is indicated for externally contracted wind-cold afflicting those with an exterior deficiency constitution. The symptoms are aversion to

wind, fever, perspiration, headache, congested and noisy nose, and dry retching. The tongue has a white coating, there is no thirst, and the pulse is either superficial and moderate or superficial and weak.

Analysis of Fundamental Pattern Pathogenesis 1 Sun Guang-quan. Successful Sample Cases of Using Má Huáng Tāng with Additions 麻黄汤加 味验案举隅. Liaoning TCM Magazine. 1989; (12): 20.

This pattern is caused by externally contracted wind-cold and disharmony between ying and wei qi. The Treatise on Cold Damage says “wind attacks the taiyang channel” [3], and “the ying is weak while wei is strong”[4]. The statement “wei is strong” refers to an external attack by windcold that elicits a strong fight from the wei qi against the pathogen. Due to a disturbance of the channels, there is fever, headache, and a superficial pulse. “Ying is weak” refers to the loss of ying yin that occurs due to the insecurity of wei yang. Insecurity of wei qi is an impairment of healthy qi. Fluids leak out as perspiration; therefore there is aversion to wind, and a moderate pulse.

Formula Actions Releases the flesh and the exterior; harmonizes ying and wei levels.

Formula Analysis

Unique Combination Features This formula nourishes while it expels and astringes while it dispels. It simultaneously fights pathogens while it supports healthy qi, and it regulates both yin and yang. In Collected Writings on the Renewal of the ‘Treatise on Cold Damage’ (Shāng Hán Lái Sū Jí, 伤寒来苏集), Ke Qin praised this formula as “the best among Zhang Zhong-jing’s formulas. It nurtures yin, harmonizes yang, and harmonizes the ying and wei levels. It is a masterful formula for releasing pathogenic factors from the muscles and skin and to induce sweating”[5].

Further Clarification If this formula is indicated for patterns in which there is already sweating, why use Guì Zhī Tāng to further induce sweating?

In the Guì Zhī Tāng pattern, body fluids leak out of the body as sweat. This happens because an external attack of wind-cold results in the insecurity of wei yang and damages ying yin. Therefore, if one does not eliminate the external pathogen, ying and wei will lack harmony, and the sweating will not stop. Although Guì Zhī Tāng is said to induce sweating while releasing pathogens from the flesh and exterior, it also regulates the ying and wei levels. Once the external pathogens are released, the surface will become secure. When ying and wei are harmonious the fluids will not leak out. Therefore, when Guì Zhī Tāng is used as directed, after it induces a light sweat over the entire body, the sweating described in the original pattern automatically stops. The sweat that results from an external wind-cold with exterior deficiency pattern is referred to as a “pathological sweat”, while the sweat induced by Guì Zhī Tāng is referred to as “medicinal sweat”. The distinction of the two is that pathological sweating often comes with chills, aversion to wind, and headache, while medicinal sweating often comes with warmth and slight sweating over the entire body, which is followed by recovery.

Formula Applications 1. Essential pattern differentiation Guì Zhī Tāng is the basic formula used to treat external wind-cold invasion in an exterior deficiency pattern. This formula also harmonizes the ying and wei levels as well as yin and yang. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of an exterior deficiency wind-cold pattern: common cold, flu, upper respiratory tract infection; and when the patient shows signs of disharmony between ying qi and wei qi: rheumatic arthritis, erythema multiforme, urticaria, cutaneous pruritus, allergic rhinitis, and vomiting in pregnancy. 4. Cautions and contraindications It is not applicable for patients diagnosed with a wind-cold exteriorexcess pattern with an absence of perspiration. While taking the formula, the patient should avoid raw, cold, oily or odorous food, alcohol, and meats.

Associated Formulas Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction Plus Pueraria, 桂枝加葛根汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Add 1 dou of water to decoct gé gēn until 80% water remains. The decoction should be taken warm and the patient should bundle up with an extra layer to induce a mild sweat. [Actions] Releases pathogens from the muscles and skin, ascends fluids to comfort the sinews. [Applicable Patterns] Presentation of a Guì Zhī Tāng pattern with a stiff neck and back. Guì Zhī Jiā Hòu Pò Xìng Zĭ Tāng (Cinnamon Twig Decoction Plus Magnolia and Apricot, 桂枝加厚朴杏⼦汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. The decoction should be taken warm and the patient should bundle up with an extra layer to induce a mild sweat. [Actions] Releases pathogens from the muscles and skin, descends qi to relieve shortness of breath.

[Applicable Patterns] Presentation of a Guì Zhī Tāng pattern with slight labored breathing. The pathomechanism for both formulas is the presentation of exterior wind-cold with disharmony of the ying and wei qi which calls for Guì Zhī Tāng to harmonize the ying and wei levels and the yin and yang. Guì Zhī Jiā Gé Gēn Tāng is used for external wind-cold when there is also qi constraint in the taiyang channel obstructing fluid distribution and causing a lack of nourishment to the channels and collaterals. This pathomechanism further leads to aversion to wind, sweating, and stiffness of the back and neck. Guì Zhī Tāng plus gé gēn is the appropriate formula as it releases the flesh to expel pathogens from the body surface and ascends fluids to soothe the sinews. By contrast, Guì Zhī Jiā Hòu Pò Xìng Zĭ Tāng is primarily used to treat an exterior deficiency wind-cold pattern with gasping and adverse qi due to the lung’s failure to purify and descend. The addition of hòu pò and xìng rén directs qi downward and calms labored breathing.

Comparison & Contrast Má Huáng Tāng vs. Guì Zhī Tāng

Case Studies 1. Common cold Mr. Wu, age 47, a government official. Initial visit: March 10th, 1984. The patient had been catching colds frequently since the onset of spring. He experienced generalized discomfort with stiffness and distension, swollen and painful joints, and his back felt like ice water was being poured over it. Other signs and symptoms included: severe aversion to cold without fever; nasal congestion with clear, runny mucus; white and moist tongue coating; and a superficial and soft pulse. The prescription used was Guì Zhī Tāng with additions. Ingredients: guì zhī 10 g, bái sháo 10 g, gān căo 6 g, fáng fēng 6 g, wēi líng xiān 10 g, shēng jiāng 3 slices and dà zăo 3 pieces. The patient was advised to take two doses. After taking the medicine, the patient said that he felt warm like having a sunbathe; and the symptoms were gone.

He took two more doses of the previous formula with the addition of shēng huáng qí 15 g and bái zhú 10 g, and completely recovered.1 Comments: Guì Zhī Tāng is the preferred formula to treat the common cold in people with a weak constitution. By adding wind-dispelling fáng fēng and wēi líng xiān, it not only disperses wind and overcomes dampness, but also reaches out to the surface to expel pathogens. When the exterior pattern is eliminated, one can combine it with Yù Píng Fēng Săn to replenish the zheng qi, secure the surface, and harmonize the ying and wei levels, which addresses the root cause of the disease. 2. Continuous perspiration Mr. Zheng, 49 years old, government official. Initial visit: March 10th, 1958. The patient explained that he had night sweats every night, but did not pay attention to it because it was not bothering him. Later on, he started to sweat in the daytime whenever he exerted himself, and ever since he easily caught cold. The symptoms of his cold were nasal congestion with clear runny mucus, fatigue, and severe aversion to wind, and no fever. There were times that he would recover without any treatment however; he typically needed to take medicine. His pulse was superficial, moderate and deficient, and his tongue coating was white and moist. He was prescribed Guì Zhī Tāng with additions: guì zhī 10 g, bái sháo 10 g, zhì gān căo 5 g, shēng jiāng 3 slices, dà zăo 3 pieces, shēng lóng gŭ 15 g, shēng mŭ lì 15 g. The patient was advised to take two doses and come back for further adjustments. Three days later he came for his second visit. He reported that after taking the formula, the sweating was slightly reduced but without an obvious improvement. He still felt cold in the four limbs and had a stuffy and runny nose. The tongue coating was thin and white, and the pulse was superficial,

moderate and deficient. He was prescribed: guì zhī 10 g, bái sháo 10 g, zhì fù piàn 10 g, zhì gān căo 5 g, shēng jiāng 3 slices and dà zăo 3 pieces. He was advised to take three doses. Third visit: After taking the medicine, the sweating ended and the patient felt warm all over the body and in his four limbs. The pulse was moderate and soft, and the tongue coating was white and moist. He was prescribed Guì Zhī Tāng combined with Yù Píng Fēng Săn. The patient took the original Guì Zhī Tāng formula with the dosages used above combined with shēng huáng qí 15 g, fáng fēng 15 g, and bái zhú 12 g. After taking five doses the patient was completely normal.2 1 Chen Rui-chun. Practical Discussions on Cold Damage伤寒实践论. Beijing: People’s Medical Publishing House; 2003. p. 2-3. 2 Chen Rui-chun. Practical Discussions on Cold Damage伤寒实践论. Beijing: People’s Medical Publishing House; 2003. p. 6-7.

Comments:As recorded in the Treatise on Cold Damage, “for non-stop perspiration after inducing sweat, [and] aversion to wind” [6], use Guì Zhī Jiā Fù Zĭ Tāng. In this case, the patient had disharmony of the ying and wei qi, but no other illnesses in the zang organs. Although the sweat-inducing method had not been used, there was continual perspiration. Therefore, the use of Guì Zhī Jiā Fù Zĭ Tāng was effective. The follow-up treatment combined Guì Zhī Tāng with Yù Píng Fēng Săn, first to regulate the ying and wei, and second to boost the right qi for securing the surface. The combination is a clinically effective regulating formula for insecurity of the exterior due to yang deficiency. 3. Hemianesthesia Mr. Cheng, 52-year-old peasant. He had hemianesthesia for almost a year and received i.m. with VB1, VB12, i.v. with angelica and salvia miltiorrhiza solutions, and oral nervous nutritional drugs such as ATP for

two months without obvious result. His initial visit was October 16th, 2003. His premorbid physical condition was good until he got soaked in the rain while working outside. The symptoms included lassitude, anorexia, hemianesthesia on the right side of the body, occasional perspiration, aversion to wind, body aches, and restrained neck movements. The temperature on both sides of his body did not differ. The hand grip test showed that the affected side was slightly weaker than that of the unaffected side. His tongue body was light red with a thin white coating. His pulse was moderate and weak. Physical exams: body temperature 37.2℃, blood pressure 138/80 mmHg; the third, fourth and fifth cervical vertebrae exhibited different degrees of hyperosteogeny; ESR, antistreptolysin O, rheumatoid factors and uric acid were normal. The diagnosis was wind attacking the taiyang channel due to loose striae of skin and muscles that were exposed to excessive dampness without proper treatment over a period of time, which further caused disharmony of the ying and wei. Guì Zhī Tāng with modifications was prescribed to relieve muscles, dispel wind and reconcile the ying and wei. Four doses were prescribed with ingredients such as guì zhī 15 g, bái sháo 15 g, gān căo 8 g, shēng jiāng 10 pieces, dà zăo 10 pieces, fáng fēng 10 g, qín jiāo 10 g, and gé gēn 12 g. Prepare as a decoction to induce slight sweating. Symptoms such as numbness and lassitude were alleviated upon completion of the four doses. He was prescribed five more doses of the above formula with an addition of chì sháo 12 g. He completely recovered after completing the regimen and his symptoms have not recurred yet up to the date that this article was written.1 Comments: The patient developed hemianesthesia after exposure to the rain while working outdoors. He suffered aversion to cold, body pain, no sweating and a limited range of motion of the neck. These were symptoms of

an externally contracted wind-cold pattern complicated by dampness, causing imbalance of the ying and wei, blockage of qi over the taiyang channel, inability of fluid distribution and failure of nourishment to the channel. Thus, it was appropriate to use combined Guì Zhī Tāng and Gé Gēn Tāng with modifications to relieve muscles, release the exterior pathogens, and soothe the channels and collaterals. Fáng fēng and qín jiāo were added to dispel the wind-dampness and eliminate body aches.

Jiŭ Wèi Qiāng Huó Tāng 九味羌活汤Nine Ingredients Notopterygium Decoction Source Text 1 Yu Qiu-ping. A Successful Case of Treating Hemianesthesia with Modified Guì Zhī Tāng加味 桂枝汤治疗半身麻⽊验案1例. Journal of Traditional Chinese Medicine. 2004; (6): 50.

A formula of Zhang Yuan-su referenced in The Bewildering Matter (Cĭ Shì Nán Zhī: Zhāng Yuán Sù Fāng, 此事难知: 张元素⽅)

Formula Ingredients

Preparation and Administration Prepare Jiŭ Wèi Qiāng Huó Tāng as a decoction. The source book recommends coarsely grinding the ingredients before decocting the formula. If there is a therapeutic need to promote sweating urgently it should be taken warm followed by warm porridge to supplement the formula’s actions.

Otherwise, if mild sweating is observed then it is taken warm without the porridge.

Formula Indications Jiŭ Wèi Qiāng Huó Tāng is indicated for an exterior pattern with externally contracted windcold-dampness complicated by interior heat. The symptoms are aversion to cold, fever, absence of sweating, headache, painful stiff nape, pain and soreness of the limbs and body, bitter taste, and thirst. The tongue coating is white or light yellow, and the pulse is superficial or superficial and tight.

Analysis of Fundamental Pattern Pathogenesis When wind-cold-dampness pathogens attack the skin and superficial muscles, wei yang becomes trapped and the striae becomes tightened and closed. The channels get obstructed and there is congestion of qi and blood. Therefore, there is aversion to cold, fever, absence of sweat, headache and painful stiff nape, and general body aches. Interior heat causes bitter taste and slight thirst. The tongue coating is white or light yellow with a superficial pulse. All of these are clear indications of an exterior pattern complicated by interior heat. The treatment should emphasize dispelling windcold-dampness pathogens and clearing interior heat.

Formula Actions Induces sweating, expels dampness, and clears internal heat.

Formula Analysis

Unique Combination Features First, the formula is mainly indicated to relieve the exterior. It combines acrid-warm, ascendingdispersing medicinals with cold, heat-clearing ones.

Second, since the medicinals address the six channels, it is important to prioritize and adjust the amount of each ingredient accordingly.

Further Clarification 1. Treatment based on channel differentiation Up until approximately the Song or Yuan Dynasty, exterior patterns were treated as taiyang pattern conditions based on the Taiyang Chapters of Zhang Zhong-jing’s book. Although the taiyang channel is the first to be affected when external wind-cold and dampness pathogens attack the body, all six channels can be impacted. In this formula, qiāng huó enters the taiyang channel, cāng zhú enters the taiyin, xì xīn enters the shaoyin, chuān xiōng enters the jueyin, bái zhĭ enters the yangming, and huáng qín enters the shaoyang. This combination takes care of both the exterior and the interior with several medicinals gravitating towards specific channels. Because of this, the source book emphasizes that “although nine medicinals make up one formula, the quantity of each medicinal should not be fixed in amount” [7];

rather, a physician “needs to investigate the facts such as the sequence of

the channels affected, on which side, the number of channels, and the range and severity, in order to modify the amount of each ingredient being used in the prescription” [8]. This is the only way to reach a “marvelous effect” [9]. In modern applications, use a larger quantity of qiāng huó if the headache affects the occipital area, bái zhĭ if it affects the forehead, chuān xiōng if it affects the temporal regions and xì xīn if it extends into the mouth causing toothache. 2. Instruction of usage The efficacy of a formula is closely linked to how it is administered. In practice, the sweatinducing effect can be controlled by various methods. If

the cold pathogen is fierce with more obvious exterior signs and symptoms, the decoction should be given while it is very warm. It should be supplemented with rice porridge afterwards to enhance the medicinal effect to induce sweating and dispel pathogenic factors. If the cold pathogen is less severe as in the exterior pattern, it is not necessary to serve rice porridge, and the decoction can be taken lukewarm to induce slight sweating.

Formula Applications 1. Essential pattern differentiation This formula is commonly indicated for the pattern characterized by externally contracted windcold-dampness complicated by interior heat, and also a representative formula for the principle of “treatment based on channel differentiation”. Key signs and symptoms for pattern differentiation include:

2. Modifications

3. Modern applications

This formula may be used in biomedically defined disorders such as the common cold, acute myonitis, rheumatic arthritis, migraine headache and lumbar muscle degeneration when the patient shows signs and symptoms of exterior wind-cold-dampness pattern complicated with interior heat. 4. Cautions and contraindications Although Jiŭ Wèi Qiāng Huó Tāng contains cold natured shēng dì huáng and huáng qín, it is overall an acrid-warm, drying therapy. Consequently, it is not applicable for patients suffering neither an externally contracted wind-heat pattern nor a yin deficiency with an internal heat pattern.

Associated Formulas Dà Qiāng Huó Tāng (Major Notopterygium Decoction, ⼤羌活汤) [Source] The Bewildering Matter-Volume One (Cĭ Shì Nán Zhī, 此事难知: 卷上) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. The decoction should be taken warm. [Actions] Disperses wind-cold and removes dampness and clears heat. [Applicable Patterns]

Presentation of externally contracted wind-cold-dampness pattern complicated with interior heat. Symptoms include: headache, general heaviness, aversion to cold, fever, dry mouth, irritability, chest distress, thirst, a white-greasy tongue coating, and a rapid and superficial pulse.

Case Studies 1. Cold damage Yu Jin-bao, about 30 years old, a politician living in Shan Tou of Guangdong Province. He got caught in the rain while traveling and developed a cold with fever. A TCM physician misused Bái Hŭ Tāng, causing inner penetration of exterior pathogens that lead to intermittent fever. A Western doctor diagnosed it as malaria and treated him with quinine, only to worsen his condition. His signs and symptoms were severe aversion to cold and wind, suffocating low-grade fever, dry nose, thirst, headache, joint aches, cough, labored breathing, dysthesia, and scanty darkyellow urine. The left cùn pulse was superficial and tight, and right chĭ pulse was full and replete. Taking both the symptoms and pulse into consideration, it was concluded that his condition started as an external wind-cold affecting the taiyang that transformed into heat and offended the lung channel. He was prescribed Jiŭ Wèi Qiāng Huó Tāng: qiāng huó 2 qian (6 g), fáng fēng 1½ qian (4.5 g), cāng zhú 1 qian (3 g), huáng qín 1½ qian (4.5 g), bái zhĭ 1½ qian (4.5 g), chuān xiōng 1 qian (3 g), mù tōng 1½ qian (4.5 g) and chì fú líng 6 qian (18 g). He was given a second prescription: tíng lì zĭ 3 qian (9 g), qiān niú zĭ 2 qian (6 g), sāng bái pí 4 qian (12 g), jié gěng 1 qian (3 g), zĭ wăn 3 qian (9 g), zĭ sū zĭ 1½ qian (4.5 g), sòng gōng xià (alternative name of bàn xià) 2 qian (6 g), chì fú líng 6 qian (18 g), and tiān jīn hóng (alternative name of jú hóng) 4 pieces. The next day, the pain and perspiration stopped

but not the coughing. He was then given 3 doses of lung therapy which resolved the condition.1 1 He Lian-chen. Categorized Successful Medical Cases of Nationwide Famous Physicians全国名 医验案类编. Fuzhou: Fujian Science and Technology Press; 2003. p. 34.

Comments: The patient was caught in the rain and exhibited aversion to cold, fever, headache, and joint pain indicative of an externally contracted wind-cold-dampness pattern. He was erroneously given Bái Hŭ Tāng leading to the inner invasion of the pathogen and its transformation to heat. As a result, it turned into a depressed wind-cold-dampness with interior heat pattern. He was then treated with a variation of Jiŭ Wèi Qiāng Huó Tāng to induce sweat, dispel dampness and clear interior heat. The prescription precisely targeted the pathomechanism of the disease and stopped the sweating and pain with just one dose. On his second visit, although the external wind-cold was released, the coughing caused by interior heat and phlegm congested in the lung was not resolved. Thus, he was given Tìng Lì Wán (Pepperweed Seed Pill, 葶苈丸) and Xiè Bái Săn (White-Draining Powder, 泻⽩散) with additions to clear the lung heat, dissolve phlegm and stop coughing. 2. Cold damage with myofibrositis A 44-year-old teacher. Her first visit was on July 5th. The previous night she ran out to do an errand and it was windy. When she woke next morning, the right lateral side of her back and scapular region was aching. The range of motion was limited when she lifted and rotated her right arm and when she sat down and got up. The diagnosis made by medical physician was myofibrositis of the back muscles. She turned to traditional Chinese medicine for help. She had a grimacing facial expression and her left shoulder was raised while her right shoulder dropped. A physical exam discovered obvious tenderness and stiffness over the post-scapular region

and latissimus dorsi muscle groups. Her pulse was wiry and thready and her tongue coating was thin, white and greasy. The pattern was diagnosed as sluggish wind-cold-dampness obstructing the channels and collaterals causing the blockage of qi and blood. The treatment was aimed to dispel wind-cold-dampness, invigorate blood circulation, unblock collaterals and relieve pain. The prescription included the following medicinals: qiāng huó 6 g, fáng fēng 10 g, chuān xiōng 6 g, dāng guī 6 g, bái zhĭ 6 g, cāng zhú 6 g, xì xīn 3 g, tiān xiān téng 12 g, and wŭ líng zhī 10 g. On July 6th, she came for a follow-up visit and reported that she felt relaxation on the right side of her back and scapular area within half an hour after her first intake of the decoction. After she completed five doses, both her shoulders returned to normal with only minor discomfort remaining in the scapular region. Two more doses of the same prescription completely resolved her illness.1 Comments: The patient went out on a windy night and then suffered pain and stiffness on the right side of her back and scapular area upon waking the next morning. She had a wiry, thready pulse and thin, white and greasy tongue coating. These signs clearly indicate that the disease was caused by stagnant wind-cold-dampness blocking the channels and collaterals and the transportation of qi and blood. As a result, Jiŭ Wèi Qiāng Huó Tāng was chosen as the base formula. The addition of dāng guī and wŭ líng zhī was used to promote circulation and eliminate pain. Tiān xiān téng, with its bitter-warm nature, was added to promote qi, invigorate blood circulation, expel wind, and disperse dampness. It also assists qiāng huó to relieve bì symptoms and pain. Huáng qín and shēng dì huáng were removed because there were no signs of interior heat and they have a bitter-cold and cloying nature.

Xiāng Sū Sǎn ⾹苏散Cyperus and Perilla Power Source Text Formulas from the Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

1 Zeng Guang-hua. Clinic Application of Nine Ingredients Notopterygium Root九味羌活汤的临 床运⽤. Journal of Traditional Chinese Medicine. 1984; (4): 28.

Preparation and Administration Grind all of the medicinals into powder and blend together evenly. Boil nine grams for each dose, and take while it is warm. Xiāng Sū Săn can also be prepared as a decoction by adjusting the medicinals’ quantities based on the original ratio.

Formula Indications Xiāng Sū Săn is indicated for an externally contracted wind-cold with qi constraint pattern. Signs and symptoms are aversion to cold, general fever, headache, absence of sweating, chest and epigastric fullness and distress, lack of appetite, a thin and white tongue coating and a superficial pulse.

Analysis of Fundamental Pattern Pathogenesis Wind-cold pathogens exist all year round. This formula is indicated for a mild pattern of externally contracted wind-cold at the superficial level with internal qi constraint. The symptoms such as aversion to cold, fever, headache, absence of sweating, a thin and white tongue coating and a superficial pulse are typical manifestations of an exterior pattern. Lack of appetite, distress and fullness in the chest and abdomen reveal qi constraint. The proper treatment is to release the exterior and rectify qi. Because the impact of the external pathogens is mild, it is “appropriate [to apply] light, relaxing and soothing [medicinals], not ones with drastic effect” [10]. (Treatise on Medical Formulas-Volume One, Yī Fāng Lùn-Juàn Yī, 医⽅论· 卷⼀)

Formula Actions Scatters and dissipates external wind wind-cold, rectifies qi and harmonizes the middle jiao.

Formula Analysis

Unique Combination Features First, the formula releases the exterior and moves qi. However, its emphasis is on releasing the exterior. Second, it regulates the qi of the yinfluids with an emphasis on qi rectification.

Formula Applications 1. Essential pattern differentiation Xiāng Sū Săn is commonly indicted for external contracted wind-cold with qi constraint. It is clinically marked by:

2. Modifications

3. Modern applications This formula is often used for stomach flu in those exhibiting an externally contracted wind-cold with qi constraint pattern.

Associated Formulas Xiāng Sū Cōng Chĭ Tāng (Cyperus, Perilla, Scallion and Soybean Decoction, ⾹苏葱豉汤) [Source] Revised Popular Guide to ‘Treatise on Cold Damage’ (Chóng Dìng Tōng Sú Shāng Hán Lùn, 重订通俗伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions]

Induces sweat to release the exterior, regulates qi, and prevents miscarriage. [Applicable Patterns] Cold damage during pregnancy. Symptoms include: aversion to cold, absence of sweating, fever, headache, body aches, distention in the chest and epigastric area, a thin and white tongue coating, and a superficial pulse. Jiā Wèi Xiāng Sū Săn (Supplemented Cyperus and Perilla Powder, 加 味⾹苏散) [Source] Medical Revelations-Vol. 2 (Yī Xué Xīn Wù-Juàn Èr, 医学⼼悟·卷2) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. The decoction should be taken warm and the patient should bundle up with an extra layer to induce a mild sweat. [Actions] Induces sweating to release the exterior, rectifies qi and resolves constraint. [Applicable Patterns] Externally contracted wind-cold complicated by a constrained qi pattern. Symptoms include: headache, rigid neck, nasal congestion, runny nose, body pain, aversion to cold or wind, fever, absence of sweating,

distressed chest and abdominal area, a thin and white tongue coating, and a superficial pulse. Both formulas are derived from Xiāng Sū Săn with certain added medicinals. They are indicated for the pattern of exterior cold and stagnant qi. Xiāng Sū Cōng Chĭ Tāng, which combines Xiāng Sū Săn and Cōng Chĭ Tāng, was designed by Yu Gen-chu. The exterior-releasing effect and miscarriagepreventing effect is stronger than Xiāng Sū Săn. It is appropriate for pregnant women with externally contracted wind-cold. Jiā Wèi Xiāng Sū Săn though, by adding fáng fēng, qín jiāo, chuān xiōng, and màn jīng zĭ, is stronger for inducing sweat, releasing the exterior, dispelling bì symptoms and stopping pain. Thus, it is better for more severe external cold patterns with obvious headache and body aches.

Case Studies 1. Common cold Ms. Zhang, age 31. Initial visit: December 8th, 1999. The patient has a weak constitution and catches colds easily. She came down with a cold two weeks ago. It was slightly alleviated by taking jīn yín huā, lián qiào and Vitamin C Combo tablets but continued to recur on and off. The symptoms were mild aversion to cold, fever, nasal congestion, body heaviness, pharyngeal itchiness and cough. An examination revealed redness of the pharynx, a red tongue body, a white and slightly greasy coating, and a soggy pulse. The diagnosis was an externally contracted wind-cold pattern complicated by heat and dampness. Prescription: Xiāng Sū Săn plus pú gōng yīng, băn lán gēn, huò xiāng, and xìng rén. After she completed three doses, she felt comfortable with all of her symptoms relieved.1

Comments: The patient had a mild exterior cold pattern and a weak constitution. Instead of using a heavy acrid-warm formula that may have harmed the exterior, Xiāng Sū Săn was used to gently relax the surface, induce mild sweating, and release pathogenic factors. Pharyngeal itchiness and cough was due to the disturbed lung system which could be resolved by adding qi-descending xìng rén and lung-diffusing zĭ sū yè. Symptoms of damp-heat were marked by the red tongue, the white and slightly greasy tongue coating, and the soggy pulse. Therefore, pú gōng yīng, băn lán gēn, and huò xiāng were added to clear heat and transform dampness. 2. Stomachache 1 Mai Zhen-rong, Huang Ge-ning. Using Xiāng Sū Săn Extra to Treat 168 Cases of Four-season Cold⾹苏散加味治疗四时感冒168例. Journal of Practical Traditional Chinese Medicine. 2001; (7): 18.

Ms. Gong, age 19, student. Initial visit: December 9th, 1959. She had severe aversion to cold, headache, stiffness of the neck, general body pain, stomachache, a distended upper abdomen, belching, reflux, and regurgitation. When she ate, although it was only a little bit, it aggravated her stomachache and she suffered from incomplete defecation. The tongue body was pale red, and the pulse was superficial and moderate. The pattern was stagnant cold in the muscle layer, complicated by ascending counterflow of the stomach qi. The applicable treatment was to rectify qi, release the exterior, harmonize the middle jiao and descend ascending counterflow qi. The treatment strategy was to use the combination of Xiāng Sū Săn and Xuán Fù Dài Zhĕ Tāng with modifications. Ingredients: xiāng fù 10 g, entire zĭ sū yè 10 g, chén pí 6 g, qín jiāo 10 g, fáng fēng 10 g, bàn xià 10 g, dài zhĕ shí 12 g, shì dì 7 pieces, wū zéi gŭ 10g, xuán fù huā 10 g, shēng jiāng 3 g, dà zăo 3 pieces, and gān căo 3 g. She was prescribed three doses. Upon her second visit, she was free from the aversion to cold, headache and body

aches with other symptoms alleviated. However, she still had hiccups, belching, regurgitation, stomachache that extended into the abdomen, and loose stool. Her pulse became stringy and moderate. The proper treatment is to tonify the spleen, harmonize the stomach, control acid reflux and descend ascending counterflow stomach qi. The prescription was modified accordingly: xuán fù huā 10 g, dăng shēn 12 g, fă bàn xià 10 g, dài zhĕ shí 15 g, wū yào 12 g, băi hé 25 g, wú zhū yú 5 g, wū zéi gŭ 10 g, bái zhú 10 g, zhì gān căo 5 g, shēng jiāng 6 g, and dà zăo 6 g. She was given three doses repetitively at her third, fourth, and fifth visit. Her sixth visit was on December 24th, 1959. The stomachache, hiccups, belching, and acid reflux were eliminated and her stool returned normal. The only remaining symptom was a cold sensation in her epigastric area that favored warmth and pressure. The treatment plan was to use the previous prescription by removing wū zéi gŭ, and replacing shēng jiāng with páo jiāng. After completing some 20 doses, she recovered and was dismissed from the hospital.1 Comments: Symptoms in this case were aversion to cold, headache, neck stiffness, general pain, epigastric pain and distention with frequent belching, acid reflux and hiccups. The condition affected both the exterior and interior, that is, externally contracted wind-cold and ascending counterflow rising stomach qi. The proper treatment method was to simultaneously treat both the exterior and interior. The formula chosen was Xiāng Sū Săn supplemented to release the exterior, regulate qi, harmonize the stomach and descend ascending counterflow qi. By combining zĭ sū yè, fáng fēng and qín jiāo, the exterior was released and pathogens were expelled. By mixing xiāng fù, chén pí, bàn xià, dài zhĕ shí and shì dì, it could rectify qi, relieve pain, harmonize the stomach, and settle ascending counterflow. Wū zéi gŭ relieves acidity and pain. Her exterior symptoms were relieved by her second visit. Therefore, she was prescribed Xuán Fù

Dài Zhĕ Tāng plus băi hé, bái zhú, and wú zhū yú to fortify spleen, calm the stomach, control acid reflux and descend ascending counterflow qi. By her sixth visit, the acid reflux stopped but the cold feeling in her stomach area that had preferred warmth and pressure had not gone. Consequently, wū zéi gŭ was removed from the prescription and páo jiāng replaced shēng jiāng to warm the spleen and regulate stomach.

Xiăo Qīng Lóng Tāng ⼩青龙汤Minor Green Dragon Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

1 Lin Ke-yu. Successful Cases of Treating Sophisticated and Refractory Disease Patterns with Traditional Chinese Medicine疑难病证中医治验. Changsha: Hunan Science and Technology Press; 1983. p. 67.

Preparation and Administration Prepare Xiăo Qīng Lóng Tāng as a decoction to be taken warm. The source text points out that má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals.

Formula Indications This formula is indicated for the pattern of exterior cold with interior fluid retention. The symptoms are aversion to cold, fever, absence of sweating, labored breathing, cough, copious clear and thin phlegm, stuffiness in chest, dry retching, difficulty lying back in the supine position, general body aches, edema of the face and extremities. The tongue coating is white and glossy, and the pulse is superficial.

Analysis of Fundamental Pattern Pathogenesis Xiăo Qīng Lóng Tāng is indicated when an excessive fluid condition is complicated by externally contracted wind-cold. Aversion to cold, fever, absence of sweating and body aches are symptoms of an exterior excess pattern with wind-cold fettering the exterior causing obstruction of the wei yang and constraint of ying yin. When a person who has excessive fluids contracts an external pathogen, the pathological activities of the excessive fluids may be initiated. Cold thin phlegm then invades the lung and causes the lung qi to fail to diffuse and descend which leads to cough, labored breathing and copious thin sputum. Stuffiness in chest is due to fluid retention under the heart blocking the qi movement. Dry retching is caused by lodged fluid that causes ascending counterflow of the stomach qi. General edema and heaviness is due to subcutaneous water retention. And finally, a white and glossy coating and superficial pulse are clear signs of exterior cold with interior fluid retention. In this situation, dispersing external pathogens alone without dissolving fluid retention will not resolve the excessive internal fluids. On the other hand, dissolving fluid retention alone without expelling external pathogens will not release the exterior. Therefore, the correct treatment method is to simultaneously address both the internal and external by relieving the exterior and dissolving fluid retention.

Formula Actions Releases the exterior, dissipates cold, warms the lung and dissolves rheum (fluid retention).

Formula Analysis

Unique Combination Features

First, the formula releases the exterior and dissolves fluid retention, with an emphasis on releasing the exterior. Second, it takes both branch and root into consideration and therefore concurrently regulates both the spleen and the lung. Third, it uses the special herbal combination theories of astringency within dissipation (the addition of astringents to medicinals that dissipate), and closing within opening (the addition of astringents to medicinals that release the exterior).

Further Clarification For most exterior patterns, especially those with cough and phlegm, it is contraindicated to combine astringent medicinals with acrid medicinals. Then, why does Xiăo Qīng Lóng Tāng, an acrid formula, contain astringents wŭ wèi zĭ and bái sháo? It is designed for patients with an internal excessive fluid condition who have contracted external wind-cold, triggering abnormal movement of internal fluids. Generally, acrid-warm dispersing medicinals are indicated for externally contracted wind-cold with closed pores and orifices. However, those with internal cold thin phlegm already have deficient spleen and lung. If drastic sweat-inducing therapy is used, it will damage the lung qi and yin-fluids. Consequently, the way to make the best of both is to combine both dispersing and astringent medicinals to conserve qi and yin. In this formula, má huáng and guì zhī reinforce each other to induce sweat and expel pathogens. Shēng jiāng, xì xīn and bàn xià warm the lung and transform thin phlegm. These five are all acrid-warm medicinals. To the contrary, wŭ wèi zĭ astringes the lung and relieves cough while bái sháo astringes yin and nourishes blood. By combining these two medicinals with the previous five medicinals that have opposite yet complementary actions, the formula induces sweating with acrid-warm medicinals and prevents qi and yin damage without retaining pathogens. Furthermore, wŭ wèi zĭ and bái

sháo are not only used to check and balance other medicinals, they also assist the formula to relieve cough and calm labored breathing. The action of wŭ wèi zĭ to relieve cough and calm labored breathing is backed by ancient herbal classical literature while bái sháo has been proven to alleviate bronchial spasm by modern studies in Chinese medicine pharmacology. It is therefore obvious that, these two medicinals will enhance the formula’s action to calm labored breathing.

Formula Applications 1. Essential pattern differentiation Xiăo Qīng Lóng Tāng is commonly indicated for the pattern of externally contracted wind-cold with cough and labored breathing due to internal cold thin phlegm. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in biomedically defined disorders such as bronchitis, bronchial asthma, pneumonia, pertussis, pulmonary heart disease, allergic rhinitis, and catarrhal ophthalmic and catarrhal tympanitis when the patient shows signs of external cold and internal fluid retention. 4. Cautions and contraindication Due to the relatively strong acrid-dispersing and warm-resolving effects of the formula, it is only indicated for those who are indeed affected by external cold interacting with internal fluids causing a disorder of the lung system. The dosage needs be determined according to the physical constitution of the patient. It is not applicable for coughs without sputum due to a yin deficiency or internal phlegm-heat pattern.

Associated Formulas Shè Gān Má Huáng Tāng (Belamcanda and Ephedra Decoction, 射⼲ 麻黄汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals. The decoction should be taken warm.

[Actions] Diffuses the lung, dispels phlegm, lowers qi and relieves cough. [Applicable Patterns] Congested phlegm and fluids complicated with cough and labored breathing. Symptoms include: cough, breathing due to ascending counterflow qi, labored breathing, and a continuous rattling sound in the larynx caused by sputum blockage.

Case Studies 1. Cough 6-year-old child. The patient went fishing with his grandfather and contracted external windcold and developed a cough with sticky phlegm. A previous doctor prescribed Xuán Fù Dài Zhĕ Tāng which stopped the coughing. His symptoms were a deep, harsh voice, excessive saliva, rattling phlegm, rapid breath that moved his alla nasi, labored breathing with elevated shoulders, heaving chest, dysphoria, dysuria, and disturbed defecation. His left pulse was wiry and thready and the right one was hidden. The child was prescribed Zhang Zhong-jing’s Xiăo Qīng Lóng Tāng. The ingredients were: guì zhī 2 g, bái sháo 15 g, bàn xià 15 g, xì xīn 1.5 g, prepared má huáng 1 g, zhì gān căo 2 g, gān jiāng 1.5 g and wŭ wèi zĭ 1.5 g. The labored breathing was relieved after one dose and the second dose relieved the cough, cleared the phlegm and normalized excretions. 1 1 Xiong Liao-sheng. New Annotation of Famous Cold Damage Cases 伤寒名案选新注. Chengdu: Sichuan People’s Publishing House; 1981. p. 29.

Comments: This case was a typical Xiăo Qīng Lóng Tāng pattern. All the medicinals of the formula were used with significantly reduced amounts of má huáng and xì xīn suitable for a 6-yearold child in order to avoid

excessive dispersion. Dr. Xiong described the case as a cold damage cough pattern due to externally contracted cold with interior fluid retention. It was an evening of the third month of winter when the child was invaded by wind-cold and there was clear evidence of external cold and interior fluid retention. The first doctor did not analyze the root cause of the disease and used Xuán Fù Dài Zhĕ Tāng. It is a formula used to supplement deficiency, diffuse qi, clear up phlegm and contain counterflow to treat cough. The medicinals used in that formula to direct counterflow downward and supplement deficiency led to constraint of the wind-cold pathogen. Thereafter, the disease evolved to reveal urgent symptoms. His deep, harsh voice was due to “metallic lung failing to sound” caused by excess pathogens. Other symptoms included rapid breath, flaring alla nasi, copious saliva, rattling phlegm, vexation, dysuria, and disturbed defecation. In face of this imminent danger, the treatment could not afford to be erroneous again. The condition could only be resolved with Xiăo Qīng Lóng Tāng to warm the lung, disperse cold, transform phlegm, and lower counterflow. The first dose calmed the labored breathing, and the second one relieved the cough, helped him to expectorate sputum, regulated urination and normalized the bowel movement. 2. Asthma Song, 55-year-old male. His first visit was on June 19th, 1978, with chief complaints of pulmonary tuberculosis, asthma and emphysema for more than 10 years. A chest X-ray revealed increased lung markings, emphysema and lymph node calcification of the lung hilus. He had asthma attacks for half a month which worsened in the afternoon with other symptoms including aversion to cold, nasal congestion and thirst. He took aminophylline for ten days without improvement. He had a yellow and greasy tongue coating and a superficial and wiry pulse. The pattern

identification was lung deficiency with phlegm-fire complicated by external wind-cold. The treatment method chosen was to treat the urgent symptoms (branch) first with modified Xiăo Qīng Lóng Jiā Shí Gāo Tāng. Ingredients: má huáng 5 g, xì xīn 3 g, zhì bàn xià 10 g, gān jiāng 4 g, wŭ wèi zĭ 5 g, guì zhī 7 g, gān căo 5 g, shēng shí gāo 30 g, bĕi shā shēn 10 g, mài dōng 10 g and kŭ xìng rén 10 g. His second visit was on June 21st, 1978. The asthma was slightly alleviated however there remained an aversion to wind and mild thirst. The tongue and pulse signs remained unchanged. The same treatment method was applied with modifications. The medicinals used include má huáng 7 g, xì xīn 4 g, zhì bàn xià 10 g, gān jiāng 5 g, wŭ wèi zĭ 12 g, tíng lì zĭ 12 g (gauze wrapped), guì zhī 10 g, shēng shí gāo 30 g, kŭ xìng rén 10 g, prepared mă dōu líng 7 g, bĕi shā shēn 10 g, shēng gān căo 5 g and dăng shēn 10 g. After taking this formula, the symptoms of asthma were eliminated and thus treatment using the qiboosting and phlegm-transforming methods was begun.1 Comments: The asthma of the patient was caused by lung deficiency and phlegm-fire complicated by external wind-cold contraction. The treatment needed to primarily purge the pathogens and therefore a modified Xiăo Qīng Lóng Jiā Shí Gāo Tāng was prescribed. Although there was an accurate pattern differentiation on the initial visit, the light-weight dose was insufficient for the situation to bring about an obvious effect. Therefore the quantity of some medicinals was increased in the second prescription and lung-purifying, phlegm-transforming tíng lì zĭ and mă dōu líng were added to significantly improve the formula’s efficacy. This case shows that diagnosing the correct pattern and choosing the appropriate formula and medicinals is not always sufficient. The amount of each medicinal and the necessary modifications are also important. The characteristic feature of asthma is deficiency in origin and excess in manifestation. Deficiency in

both the lung and spleen allow for attacks and are easily affected by external pathogens. Thus, the prescription given at the second visit added dăng shēn, which implied how necessary it was to reinforce and boost qi.

Zhĭ Sòu Săn ⽌嗽散Cough-Stopping Powder Source Text Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟) 1 Dong Jian-hua. Elite Medical Cases of Famous Modern TCM Doctors 中国现代名中医医案精 华. Beijing: Beijing Publishing House; 1990: 469.

Formula Ingredients

Preparation and Administration Grind all of the medicinals into powder and blend together evenly. Boil 9 g for each dose, and take warm after meals and prior to bed time. Mix together with a decoction of shēng jiāng for early stage wind-cold contraction. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratio.

Formula Indications Zhĭ Sòu Săn is indicated for the pattern of wind pathogens attacking the lung. The symptoms are cough, itchiness in the pharynx, difficulty in

coughing up sputum, or mild aversion to wind and fever. The tongue coating is thin and white, and the pulse is superficial and moderate.

Analysis of Fundamental Pattern Pathogenesis This formula is indicated when an exterior pattern with cough is not relieved after taking exterior-releasing lung-diffusing remedies. When windpathogens attack the lung, they fail to diffuse and purify the lung qi. By scattering and dissipating medicinals it is possible to expel the majority of the pathogen. However, in this case, there are residual pathogens that cause cough, itchiness of the pharynx, aversion to wind and fever. The treatment is to rectify the lung and relieve cough by using a small amount of exterior releasing medicinals.

Formula Actions Diffuses and benefits the lung qi, disperses wind and relieves cough.

Formula Analysis

Continued

Unique Combination Features This formula is warm but not drying and moist but not cloying. It releases the exterior but does not harm the healthy qi. It is exactly as it is described in Medical Revelations-Volume Three: “The formula is warm, moistening, and gentle, neither cold nor blazing. [It does] not attack excessively, yet it expels pathogens by opening up the exits. Therefore, it makes it easier for the intruding pathogens to escape and the lung qi to be relaxed and calm.” It is an effective formula to use for either acute or chronic coughs and for phlegm that is difficult to expectorate when properly modified.

Formula Applications 1. Essential pattern differentiation Zhĭ Sòu Săn is a commonly used formula for cough caused by the failure of the lung to diffuse qi with a concomitant residual exterior pathogen. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of a residual exterior pathogen causing failure of the lung to diffuse: upper respiratory tract infection, bronchitis, and pertussis. 4. Cautions and contraindications This formula is warm and moistening but predominately warm. Therefore, it is inappropriate for a cough caused by yin deficiency consumption or lung heat.

Associated Formulas Jīn Fèi Căo Săn (Inula Powder, ⾦沸草散) [Source] Extensive Relieving Formulas (Bó Jì Fāng, 博济⽅) [Ingredients]

[Preparation and Administration] Grind to powder. 2 qian (6 g) per dose, mix with a small cup of water. [Actions] Disperses wind-cold, lowers counterflowing qi, and dissolves phlegm. [Applicable Patterns] Cough due to wind damage (common cold). Symptoms include: aversion to cold, fever, cough with large amount of phlegm, stuffy and nasal

congestion, white and greasy tongue coating, and a superficial pulse. Both Jīn Fèi Căo Săn and Zhĭ Sòu Săn are able to release the exterior, dissolve phlegm and relieve cough, and may be used to treat cough due to wind-pathogen attacking the lung. The latter is especially good for comforting the lung and eliminating cough, but it is insufficient for releasing the exterior. It is more appropriately used for a cough in a case where the exterior pathogen is nearly exhausted and there is dysfunction of the lung qi. Jīn Fèi Căo Săn has a greater effect to release the exterior and disperse cold; therefore, it is indicated for coughing during the initial stage when the wind pathogen attacks the lung indicating a heavier exterior pattern.

Case Studies 1. Bronchitis Gao, 58 years of age, suffered from bronchitis with persistent symptoms of coughing that was aggravated at night, laryngeal itchiness, chest oppression and excessive phlegm. He was prescribed jīng jiè 6 g, qián hú 9 g, bái qián 6 g, xìng rén 9 g, bèi mŭ 9 g, huà jú hóng 6 g, lián qiào 9 g, băi bù 9 g, zĭ wăn 9 g, jié gĕng 6 g, lú gēn 6 g and gān căo 3 g. Following the treatment, it was evident that most of the symptoms were alleviated, including the disappearance of night coughing, except for slight laborious breathing and excessive phlegm. Hăi fú shí 9 g and zĭ sū zĭ 9 g were added to the previous prescription, and four doses were prescribed. His follow-up appointment revealed that he recovered.1 Comments: According to traditional Chinese medicine, bronchitis is typically caused by external pathogens. Inappropriate treatments may cause forceful suppression of the cough or stagnation of qi and phlegm resulting in a chronic, protracted condition. In this case, the night cough and larynx

itchiness appeared concurrently due to a residual wind pathogen and lung qi failing to diffuse. The formula was used to diffuse the lung qi, dissipate wind and relieve cough. Chest oppression and massive sputum were indications that the lung is obstructed by turbid phlegm; therefore, xìng rén, bèi mŭ, hăi fú shí and zĭ sū zĭ (dosages not recorded) were used to dispel phlegm, relieve cough and soothe the throat. 2. Laryngeal cough Zhang, female, 42-year-old government office worker. Initial visit: July 19th, 2003. She had a common cold and was treated with anti-inflammatory and antitussive prescriptive drugs three months ago. All her symptoms were relieved except for an itchy larynx and a dry cough, for which there were some days that were better than others. A week ago she ate spicy food. Afterwards, her cough worsened and her larynx got itchier and became sore. Every time the itch was aggravated, she would start to cough. At times it became episodic as if she was choking. During the coughing episode, especially at night, her face and eyes would turn red, her eyes would tear up and there was nasal discharge. Other symptoms included dry mouth, dry throat and poor appetite. Urination and bowel movement were normal. The tongue was light red with a thin, white coating, and the pulse was thready. On physical examination mild laryngeal hyperemia and folliculi lymphaticus hyperplasia on the laryngeal walls were found. Respiratory sounds, blood exam and chest X-ray results were normal. The diagnosis was laryngeal cough. The proper treatment was to scatter wind, soothe the throat, diffuse the lung, moisten dryness and relieve cough. Modified Zhĭ Sòu Săn was prescribed: zĭ wăn 12 g, băi bù 10 g, jīng jiè 10 g, jié gĕng 6 g, bái qián 10 g, chén pí 10 g, sāng bái pí 15 g, huáng qín 10 g, xìng rén 10 g, chán tuì 10 g, bái jiāng cán 10 g, mài mén dōng 15 g, shā shēn 20 g and gān căo 10 g. The formula was prepared as a decoction and one dose was taken per day.

Her symptoms were significantly alleviated after three doses. With six doses, she was cured.1 1 China Academy of Traditional Chinese Medicine. Collection of Yue Mei-zhong Medical Cases 岳美中医案集. Beijing: People's Medical Publishing House; 1978. p. 107.

Comments: Laryngeal cough is described within the cough category in traditional Chinese medicine. The larynx is part of the lung system. When it is attacked by external pathogens, the lung system becomes obstructed causing laryngeal itchiness and cough. A light red tongue with a thin, white coating is a sign of residual exterior pathogens. In the case above, Zhĭ Sòu Săn was used to diffuse the lung, scatter wind, relieve cough and soothe the larynx. Adding chán tuì and bái jiāng cán helped to completely vent the exterior pathogens and to clear and soothe the throat. The addition of sāng bái pí and huáng qín was to clear the lung and dissolve phlegm. The exacerbated coughing with a dry mouth and throat following spicy food were indications of damaged lung fluid. Thus, mài mén dōng and shā shēn were added to moisten the lung and promote fluid production. With the combination of these medicinals, not only did the formula eliminate the root cause of the disease, but also relieved cough, dissolved phlegm, soothed the larynx and resolved itchiness.

Zhèng Chái Hú Yĭn 正柴胡饮Bupleurum Correction Beverage Source Text The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书)

Formula Ingredients

Preparation and Administration Prepare as a decoction to be taken warm.

Formula Indications 1 Li Wei. Treating 120 Cases of Laryngeal Cough with Modified Zhĭ Sòu Săn ⽌嗽散加减治疗 喉源性咳嗽120例. Hebei: Journal of Traditional Chinese Medicine. 2005; (6): 427.

Zhèng Chái Hú Yĭn is indicated for a mild pattern of externally contracted wind-cold. The symptoms are mild aversion to wind-cold, fever, absence of sweating, headache, general body pain, a thin and white tongue coating and a superficial pulse.

Analysis of Fundamental Pattern Pathogenesis Aversion to cold, fever, absence of sweating, headache, general body pain, thin tongue coating and superficial pulse are signs of externally contracted wind-cold. Because the contraction of the pathogen is mild, the symptoms are slight aversion to cold and fever. The appropriate treatment is to release the exterior and dissipate cold.

Formula Actions Releases the exterior and disperses cold.

Formula Analysis

Unique Combination Features Zhèng Chái Hú Yĭn has a gentle nature. It is a mild acrid-warm formula used to release the exterior. It is acrid but not dramatically so, and it is warm while not too drying.

Further Clarification Combination essentials of the formula: It is appropriate to use acridwarm medicinals to release the exterior of externally contracted wind-cold. However, when the exterior cold pattern is mild, it is enough to gently release the surface of the muscles and induce a slight sweat to vent the pathogens. It is not necessary to use a heavy acrid-warm formula which may damage the surface. Therefore, Zhang Jie-bin combined acrid-cool chái hú with acrid-warm fáng fēng and shēng jiāng to “gently disperse” wind-cold pathogens as a new approach for treating exterior cold patterns.

Formula Applications 1. Essential pattern differentiation This is a representative gentle-dispersing formula created by Zhang Jiebin. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in biomedically defined disorders when there is an externally contracted wind-cold pattern without qi and blood deficiency. These may include common cold, influenza, initial stage of malaria, and common cold for women during menstruation, while pregnant or in the postpartum period.

Case Studies Common cold 40-year-old male patient. His body temperature was measured at 39°C (102.2°F). Noted symptoms were headache, body aches, aversion to cold, nasal congestion, runny nose, and an absence of sweating for one day. His tongue was pale red with a thin, white coating and his pulse was superficial and tight. His condition was diagnosed as an externally contracted wind-cold pattern. He took two doses of Zhèng Chái Hú Yĭn and his body temperature returned to normal and all of the symptoms were alleviated. 1 Comments: Absence of sweating, headache, general body pain, a white coating, and a superficial and tight pulse were symptoms of the typical externally contracted wind-cold pattern. Since the patient was sick for only a day, it was not necessary to use a heavy acrid-warm formula. Thus, the treatment method selected was “gentle dissipation” introduced by Zhang Jiebin. Two doses of Zhèng Chái Hú Yĭn were prescribed with good result.

Section 2 Acrid-Cool Exterior-Releasing Formulas 1 Xiao Zheng-jin. A Grasp of Treating Common Cold with Zhèng Chái Hú Yĭn 正柴胡饮治感冒 ⼀得. New Journal of Traditional Chinese Medicine. 1988; (2): 22.

Acrid-cool exterior-releasing formulas are appropriate for exterior patterns caused by externally contracted wind-heat or at an early stage of warm disease. The symptoms are fever, slight aversion to cold, headache, sore throat, cough, and thirst. The tip of the tongue is red with a thin, yellow coating, and the pulse is superficial and rapid. Bò he, niú bàng zĭ, sāng yè, and jú huā are examples of commonly used acrid-cool exterior-releasing medicinals found within these formulas. When a warm pathogen attacks, it is characterized by a sudden onset and fast transformation which causes the contention and binding of qi and blood to form toxins. A warm pathogen attack to the upper jiao damages the lung, so it fails to diffuse. Therefore, formulas that treat these conditions often utilize combinations such jīn yín huā with lián qiào to clear heat and resolve toxins and jié gĕng with xìng rén to diffuse and descend the lung qi. Commonly used formulas in this category are Yín Qiào Săn, Sāng Jú Yĭn, and Má Xìng Shí Gān Tāng.

Yín Qiào Săn 银翘散Lonicera and Forsythia Powder Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Take 18 g of powder per dose. Add fifteen grams of fresh lú gēn to the powder and boil to make it a beverage. It is ready when the fragrance can be smelled. It is important to not over-boil it. It can also be prepared as decoction.

Formula Indications Yín Qiào Săn is indicated for the early stage of a warm disease. The symptoms are fever, slight aversion to cold, absent or inhibited sweating, headache, thirst, cough, and sore throat. The tip of the tongue is red with a thin, yellow coating, and the pulse is superficial and rapid.

Analysis of Fundamental Pattern Pathogenesis “When the upper body suffers a warm pathogen, the lung is attacked first (Systematic Differentiation of Warm Diseases—Chapter on Exteriorly Contracted Warm-heat, Wēn Bìng Tiáo Biàn—Wài Găn Wēn Rè Piān, 温病

条辨·外感温热篇).”[11] The warm pathogen enters the mouth and nasal cavities to attack the lung in the upper jiao. Since the lung is connected with the wei qi, which becomes constrained by the warm pathogen, the distribution and retrieval of wei qi is out of control. As a result, there will be a fever, slight aversion to wind-cold, and an absence or inhibition of sweating. Since the lung fails to diffuse qi, a cough develops. Blockage of the lung system by the warm pathogen causes the throat to be sore. The pathogen also damage yin-fluids, so the patient feels thirsty. The red tongue tip, thin, white or slight yellow coating, and rapid, superficial pulse are all evidence of an early stage of warm disease. The disease mechanism of a Yín Qiào Săn pattern is the constraint of the wei qi by the warm pathogen in the initial stage, inhibiting lung distribution. It is characterized by exterior constraint and relatively serious pathogenic heat. The proper treatment method is to vent the exterior with acrid-cool, clear heat, and resolve toxins.

Formula Actions Vents the exterior with acrid-cool, clears heat, and resolves toxin.

Formula Analysis

Unique Combination Features The addition of a small amount of acrid-warm medicinals to an acridcool formula assists it to expel pathogens without jeopardizing its acrid-cool property. At the same time, the combined actions of scattering pathological wind, clearing heat, and resolving toxins can tackle the problem both exteriorly and internally by utilizing the scattering and clearing strategies simultaneously, emphasizing the scattering.

Further Clarification 1. The combination of jīn yín huā and lián qiào

Why do we use these two heat-clearing and toxin-resolving medicinals as the chief ingredients? It is because both are multifunctional. They both have the simultaneous actions to scatter wind-heat, clear heat, and resolve toxins. The actions that they embody within a formula are closely related to their combination with the other medicinals, their preparation, and the method of administration. In Yín Qiào Săn, they are combined with the exterior-releasing medicinals bò he, niú bàng zĭ, jīng jiè suì, and dàn dòu chĭ. The formula has a unique administration method: “take it immediately once the aroma can be smelled.” The actions of jīn yín huā and lián qiào are primarily scattering and secondarily clearing. The disease has a sudden onset and quick transformation, characteristic of warm pathogens. It also causes internal heat to accumulate easily, develop toxins, and become knotted with filth-turbidity. Therefore, they need to be used in a relatively large amount in their position as chief. 2. The usage of jīng jiè suì Why do we use acrid-warm jīng jiè suì when there is exterior windheat? The formula is indicated for patterns of exterior wind-heat characterized by constrained exterior wei qi and relatively heavy pathogenic heat. The symptoms include slight aversion to wind-cold and an absence of sweating due to the blockage of the exterior qi, high fever, thirst, and sore throat caused by pathogenic heat. Jīng jiè suì, with its exterior-releasing function from its acrid-warm nature, is added in order to enhance the formula’s ability to expel pathogens. It does this in tandem with acrid-cool, clearing, and resolving jīn yín huā, lián qiào, bò he, and niú bàng zĭ. Since the portion of jīng jiè suì is light, it is warm but not drying and does not change the acrid-cool property of the overall formula. Therefore, the formula is a gentle acrid-cooling preparation that gently clears, scatters, and ventilates.

3. The decoction and administration of Yín Qiào Săn All of the medicinals in this formula are light and diffusing. Their main function is to ventilate the exterior with acrid-cold. Boiling them for a long time damages their effect. This is the reason that the source book says “when the fragrance comes out, take it orally right away. Do not over-cook”[12]. “If it is boiled for too long, it will enter the middle jiao because of its rich flavor”[13], and its main actions will be altered to clear heat and resolve toxins.

Formula Applications 1. Essential pattern differentiation The source book describes Yín Qiào Săn as a gentle acrid-cool formula. It is commonly indicted for early stage wind-warmth patterns with exterior wind-heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows early signs of acute pyrogenic diseases in an early stage of warm disease with the wei qi of the lung constrained by pathogens: common cold, flu, acute tonsillitis, upper respiratory tract infection, pneumonic, measles, epidemic meningitis, type-B encephalitis, and mumps. It is also often used for dermatological diseases such as eczema, German measles, hives, sores, abscesses, furuncles, and swellings. 4. Cautions and contraindications Yín Qiào Săn is forbidden for patients with externally contracted windcold or damp-heat disease. Since there are many aromatic medicinals in the formula with a light diffusing nature. It is inappropriate to boil it for an extended period of time.

Case Studies 1. Common cold A 14-year-old female patient complained of mild aversion to cold, headache, and general malaise started in the afternoon. In the evening, she refused dinner, developed a fever, her headache became worse, had general joint pain, absence of sweating, and a stuffy nose. The tip of her tongue was red with a thin white coating, and her pulse was superficial and rapid. Her pattern was diagnosed as externally contracted wind-heat. The treatment was to dispel wind, clear heat, and release the exterior. She was prescribed a modified Yín Qiào Săn composed of jīn yín huā 9 g, lián qiào 9 g, zhú yè 6 g, jīng jiè suì 9 g, dàn dòu chĭ 9 g, lú gēn 30 g, bò he 9 g, niú bàng zĭ 9 g, gān căo 4.5 g, and shén qū 6 g. She took the decoction at 8:00 PM, sweat, and then demanded food around 10:00 PM. She was given thin rice porridge.

The next morning, her symptoms disappeared and her vitality returned to normal, so she returned to school. 1 Comments: The patient had a typical case of early stage warm disease. There was an excessive warm pathogen at the exterior wei level and her pores were blocked due to constraint of the wei yang by the pathogen. Therefore, her prescription required jīng jiè and dòu chĭ, with an increased amount of dòu chĭ to enhance the exterior ventilation and removal of the pathogen. As a result, within two hours after taking the decoction, the young lady started to sweat and the symptoms were alleviated. We can learn that by modifying the weight of the ingredients, we can regulate their exteriorreleasing and pathogen-expelling effects. 2. Abscesses Wu, an 11-year-old boy came for an initial visit on June 10th, 1962. His chief complaint was a sudden onset of fever and aversion to cold three days ago. Two days later, he felt needle-like pricking pain on his upper right arm. A western medical doctor diagnosed that he had right upper arm abscesses and sepsis. He was given an anti-infection treatment and received an incision to drain the abscess. However, he was still suffering from the high fever. Therefore, the author was invited for a panel consultation. Physical examination revealed that his body temperature was elevated to 39°C (102.2°F), he had chills, was thirsty, and sweating. His pulse was slippery and rapid, and his tongue was red and moist with a scanty yellowish coating. His pattern was differentiated as pathogenic heat at the wei level. The treatment method was to vent the pathogen to release the exterior, clear heat, and resolve toxins with acrid-cool medicinals. He was prescribed dàn dòu chĭ 9 g, charred zhī zĭ 10 g, jīng jiè 9 g, zĭ huā dì dīng 15 g, jīn yín huā 30 g, lián qiào 15 g, lú zhú gēn 30 g, huáng qín 10 g, zhú yè 10 g, pú gōng yīng 30

g, rŭ xiāng 6 g, mò yào 6 g, yì yĭ rén 15 g, and chì sháo 10 g. After taking the formula, his temperature decreased to normal, and the incision wound healed. He continued with a modification of the formula by removing zhī zĭ, dòu chĭ, jīng jiè, rŭ xiāng, and mò yào, and adding shēng dì, mŭ dān pí, and zhī mŭ. He recovered from the illness and was released from the hospital a half month later.1 1 Sun Yat-sen Medical Sciences College. Selected Topics in Chinese Formulation 中医⽅剂选讲. Guangzhou: Guangdong Science and Technology Press; 1983. p. 67.

Comments: In this case, the western medical diagnosis was a right upper arm abscess, which falls into the category of sores and ulcerations (chuāng yáng, 疮疡) in Chinese medicine. The patient had pricking pain on right upper arm, chills, fever, thirst, sweating, a red moist tongue, and a scanty yellow tongue coating as a result of the wind-heat pathogen constraining the exterior wei qi and causing stagnation of qi and blood. The treatment used was to clear heat, resolve toxins, expel the pathogen with acrid-cool medicinals, and move qi and blood. Yín Qiào Săn was modified to fulfill the treatment requirement by adding zhī zĭ, zĭ huā dì dīng, huáng qín, and pú gōng yīng to clear heat, and resolve toxin and the abscess. Rŭ xiāng, mò yào, and chì sháo were used to move qi and blood, and cool the blood in order to stop pain. Upon the second consultation, the patient’s temperature was normal, the exterior pathogen removed, and the pain eliminated. Therefore, zhī zĭ, dòu chĭ, jīng jiè, rŭ xiāng, and mò yào were removed and shēng dì, mŭ dān pí, and zhī mŭ were added to clear heat, cool blood, and nourish yin in order to consolidate the treatment efficacy and replenish the damaged yin-fluids. We can learn from this case how to amplify the heatclearing and toxin-resolving actions of Yín Qiào Săn through proper manipulation of medicinal combinations.

Sāng Jú Yĭn 桑菊饮Mulberry Leaf and Chrysanthemum Beverage Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Prepare it as a decoction. It should be taken warm. 1 Dong Jian-hua. Elite Modern Cases of Famous Chinese Medical Physicians of China-Medical Cases of Dr. Wang Wenxiong 中国现代名中医医案精华·王⽂雄医案. Beijing: Beijing Publishing House; 1990. p. 198-199.

Formula Indications

Sāng Jú Yĭn is indicated for the initial stage of a wind-warmth pattern. Coughing is the major symptom along with a low-grade fever, slight thirst, and a superficial rapid pulse.

Analysis of Fundamental Pattern Pathogenesis When the lung is attacked by wind-warmth, the lung qi fails to diffuse which results in a cough. Since the pathogen is at a relatively superficial area, the damage to the body fluids is moderate, the body does not feel too warm, and there is only minor thirst. This is a pattern of mild exterior windheat, with signs of an early stage warm disease and failure of the lung to diffuse and descent qi. In this case, the treatment method is to dissipate wind, clear heat, and ventilate the lung to stop coughing.

Formula Actions Dissipates wind and clears heat, ventilates the lung, and stops coughing.

Formula Analysis

Unique Combination Features On one hand, this formula scatters and dissipates wind-heat to remove the root cause of the disease with gentle diffusing medicinals. One the other hand, it diffuses and purifies the lung qi to stop coughing with its bitter-acrid dispersing and descending medicinals.

Further Clarification The combination of sāng yè and jú huā The disease mechanism of a Sāng Jú Yĭn pattern is mainly marked by wind-heat invading the lung channel and collaterals. Therefore, it is appropriate to track down and expel the wind-heat residing in the lung. Both sāng yè and jú huā enter the lung channel. The former is sweet, bitter, cool, and capable of moving along the collaterals of the lung. It scatters and dissipates wind-heat from the upper jiao, clears lung heat, and diffuses lung

qi to stop coughing. The latter, with its acrid, sweet, and cold properties can also scatter and dissipate wind-heat, clear the head and eyes, and purify the lung. When it is used in combination with sāng yè, the action to clear lung heat is reinforced. Therefore, the two make a common medicinal combination used to clear and vent windheat attacking the lung channel. Another underlying reason for the use of sāng yè and jú huā is to clear the liver while calming the lung. The liver governs ascending and dispersing while the lung regulates purification and descending, so that the two systems control each other and form a dynamic balance between ascending and descending. When wind-heat invades the lung, it loses its ability to purify so it overacts onto the liver and transforms into heat. The heat affecting the liver channel will then conversely exacerbate the ailment of the lung. This is referred to as wood fire tormenting metal. Therefore, we need to treat both the liver and lung at the same time. Since both sāng yè and jú huā enter the liver and lung channels, not only do they can scatter and dissipate wind-heat in the lung, they also clear the pathogenic heat in the liver channel to reestablish the mutual control of both systems.

Formula Applications 1. Essential pattern differentiation Sāng Jú Yĭn is commonly indicated for the pattern of wind-heat attacking the lung, causing cough. Due to its mild acrid-cool nature, it is necessary to add relevant medicinals for those patients with excessive lung heat. Otherwise it cannot handle more severe lung heat patterns because the formula is too light, and the condition will not resolve. Moreover, it is not applicable to patterns of wind-cold cough. This clinical pattern is marked by:

2. Modifications

3. Modern applications The formula may be used in the following biomedically defined disorders showing signs and symptoms of wind-heat attacking the lung or the liver channels: common cold, acute bronchitis, upper respiratory tract infection, pneumonia, acute conjunctivitis, and keratitis. 4. Cautions and contraindications It should not be boiled for too long because of the light diffusing nature of the medicinals in this formula.

Comparison & Contrast Yín Qiào Săn vs. Sāng Jú Yĭn

Case Studies 1. Cough On the 24th day of the fifth month, (the yĭ yŏu heaven-stem and earthbranch year of the Chinese lunar calendar), 17-year-old Liu suffered from spring warmth along with coughing blood that had been caused by choking in the 3rd month of the year. Upon the first visit, the pulse at the cun, guan, and chi positions on both sides was thready and wiry. She would have one cough with each occurrence that would be worse between 1:00-5:00 AM. The cough was characterized by the sound of wood knocking on metal caused by the wind generated by wood. The [treatment] discussed was to dissolve wind with acrid-sweet, and soften [liver] wood with sweet-cool. The prescription was composed of lián qiào 3 qian, shēng dì 3 qian, bò he 1

qian, jié gĕng 3 qian, sāng yè 3 qian, tiān dōng 1 qian, tea-treated jú huā 3 qian, gān căo 2 qian, mài dōng 3 qian, and fresh lú gēn 3 qian. By the second visit on the 28th, the cough was reduced, appetite increased, and the pulse was surging and rapid with the left side larger than that of the right. There was no change to the formula because of its effectiveness, and another four or five doses were prescribed. The third visit was on the 2nd day of the sixth month. The method of softening the liver and purifying the lung had been effective to clear the sound of wood knocking on metal and reduce the surging, rapid left pulse. At that point the acrid and qi-level medicinals were removed and sweet-moistening medicinals were added. 1 Comments: The choke-induced cough with blood that worsened before dawn and a thready, wiry pulse were signs of wind-heat affecting the liver channel. This caused the liver wood fire to torment lung metal, a situation complicated by deficient liver yin. Sāng Jú Yĭn was prescribed to scatter and dissipate wind-heat, clear the liver, and calm the lung. Shēng dì, mài dōng, and tiān dōng were added to nourish yin and soften the liver. As the formula directly corresponded to the pattern, the result was instantaneous. 2. Adenovirus pneumonia Meng, an 8-month-old female received a panel consultation on April 10th, 1961. She was diagnosed with adenovirus pneumonia and had a fever for seven days with a body temperature of 39.8°C (103.6°F). Other symptoms included cough, labored breathing, general rash, convulsions, oral ulcers, dry lips with cracks, slightly distended abdomen, and defecating five times a day with thin, loose stool. Her pulse was superficial, rapid, and forceful. Her tongue was red, a little moist, and with no coating. Her pattern was wind-heat blocking the lung, so the treatment was to ventilate the lung, dispel wind, and vent the exterior with acrid-cool medicinals. She was

prescribed one dose of sāng yè 1 qian, jú huā 1 qian, xìng rén 1 qian, bò he (towards the end of boiling) 7 fen, jié gĕng 7 fen, lú gēn 3 qian, gān căo 8 fen, lián qiào 1 qian, jiāng cán 1.5 qian, chán tuì (whole) 1.5 qian, gé gēn 1 qian, huáng qín 7 fen, and cōng bái (towards the end of boiling) 2 cun in length. It was boiled twice to get 120 ml fluids and taken warm orally several times throughout the day. On April 11th she came for her second visit and was treated with integrative medicine (i.e. Chinese and western) and her body temperature decreased to 39°C (102.2°F). She had an aura of convulsion the night before and was treated with anticonvulsive medication. Her pulse was unchanged, she had a red tongue with a light yellow coating and very little moisture, her face was red, her abdomen was slightly distended, and her four limbs were warm. Another dose of the formula was prescribed with gé gēn removed and 3 qian dàn dòu chĭ added, the preparation and administration remained the same. She had her third visit on April 12th. She presented with no fever, she had a cough but with less phlegm, her rash was gradually reducing, she was sleepy with her eyes closed most of times, her stool was more firm, and she defecated less frequently. Her abdomen was not distended anymore, her pulse was superficial and rapid, and her tongue was red with a thin white coating. Her tongue and lips were still ulcerated. The previous formula was used with cōng bái and dòu chĭ removed and 1 qian of processed pí pá yè and 7 fen of qián hú added. The preparation and administration remained the same. She took two dosages in a row and gradually recovered.2 1 Wu Tang. Wu Ju-tong’s Case Records 吴鞠通医案. Beijing: People's Medical Publishing House; 1981. p. 236. 2 China Academy of Traditional Chinese Medicine. Pu Fu-zhou’s Experience in Medical Treatment 蒲辅周医疗经验. Beijing: People’s Medical Publishing House; 1976. p. 223.

Comments: The patient had a fever for seven days, she was coughing, had labored breathing, and a superficial, rapid pulse. The disease pattern was

wind-heat obstructing the lung, and the treatment was to vent the exterior pathogen using acrid-cool medicinals, diffuse the lung, and dispel wind by using Sāng Jú Yĭn with additions. The high fever, cough, labored breathing, and convulsions indicated that both the liver and the lung were affected, and that liver wind was stirring internally. To extinguish wind and arrest convulsions, huáng qín, jiāng cán, chán tuì, and gé gēn were added. The first dose reduced the heat but the pulse was the same; therefore, gé gēn was removed and dàn dòu chĭ added to reinforce the scattering and dissipating effects. Upon the third visit, the fever was gone, but there was still cough and phlegm with a superficial and rapid pulse. Therefore, by adding processed pí pá yè and qián hú to the previous formula, it could vent the exterior pathogen, diffuse the lung, dissolve phlegm, and stop coughing.

Má Huáng Xìng Rén Gān Căo Shí Gāo Tāng麻黄杏 仁⽢草⽯膏汤Ephedra, Apricot Kernel, Gypsum and Licorice Decoction a.k.a. Má Xìng Gān Shí Tāng (麻杏⽢⽯汤) Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Prepare it as a decoction. It should be taken warm.

Formula Indications This formula is indicated for patterns of externally contracted wind causing pathogenic heat to obstruct the lung. Signs and symptoms include continuous fever, cough with rapid qi counterflow or even flaring of nostrils thirst, presence or absence of sweat, a thin white or yellowish tongue coating, and a superficial and rapid pulse.

Analysis of Fundamental Pattern Pathogenesis

This pattern is caused by exterior pathogens that penetrate the interior and transform into heat. The heat obstructs the lung which then fails to diffuse. When external wind-heat invades the exterior and is not released, thereby constrained, wind-cold transforms into heat that penetrates the interior. Consequently, both the exterior and interior heat up and cause the symptoms of continuous fever, sweating, thirst, yellow tongue coating, and a rapid pulse. With heat obstructing the lung, the lung fails to diffuse and descend. This causes cough, rapid qi counterflow, and even flaring of the nostrils. The absence of sweating, a thin white coating, and a superficial pulse are signs of residual exterior pathogens. The correct treatment method is to use acrid-cool medicinals to vent the pathogen, clear the lung, and calm panting.

Formula Actions Scatter the exterior with acrid-cool medicinals, clear heat, and calm labored breathing.

Formula Analysis

Unique Combination Features First, the formula contains both cold and warm medicinals that support each other with their opposing properties. Second, it diffuses and descends with actions that complement each other.

Further Clarification 1. The combination of má huáng and shí gāo Má huáng is acrid, slightly bitter, and warm. It has the actions to diffuse lung qi and calm labored breathing, open the striae and interstices, and release the exterior to dissipate pathogens. Shí gāo is acrid, sweet, and very cold. It clears and drains lung heat to promote fluids and releases flesh with its acrid-scattering nature to vent pathogens. The combination of an acrid, warm medicinal with an acrid-cold medicinal yields a relationship of mutual assistance. Má huáng primarily diffuses lung qi and shí gāo mostly clears lung heat. Due to the fact that both can vent pathogens, the combination removes the root cause of the disease and rectifies the function of the lung to diffuse and descend. Mutual restriction is another aspect of this combination. When má huáng is combined with shí gāo, it diffuses lung qi and calms labored breathing without aggravating heat. On the other hand, by teaming up with má huáng, shí gāo clears and resolves lung heat without suppressing the lung qi due to its coldness. They exemplify medicinal pair that complements each other with opposite properties. As the weight of shí gāo doubles that of má huáng, Má Xìng Gān Shí Tāng is regarded as an acrid cool formula. 2. Why can the formula be used whether or not there is sweat?

In the Treatise on Cold Damage, the original application of Má Xìng Gān Shí Tāng was for taiyang disease that was not cured by inducing sweat. In such a case, the wind-cold pathogen penetrated into the interior and transformed to heat, causing “presence of sweat and labored breathing”[14]. Later generations also used it in patterns of wind-cold transforming into heat, windheat attacking the lung, or interior heat with exterior cold. But why is it that we can use the formula regardless whether there is sweating or an absence of sweating? The “presence of sweat and labored breathing” is due to heat obstructing the lung. Excessive heat forces fluids out to become sweat. In the formula, shí gāo clears heat and consequently ceases sweating and calms labored breathing, so that it can be used in the presence of sweating with cough and labored breathing. The “absence of sweating with labored breathing,” [15] on the other hand, is caused by pathogens blocking the wei qi, constraining the surface flesh and pores, and result in an absence of sweat. When heat obstructs the lung, it fails to diffuse and descend causing cough and labored breathing. With the diffusing and dissipating actions of má huáng, the lung qi is free from obstruction, so that labored breathing is calmed as the pathogens are dissipated. Concurrently, shí gāo clears and drains lung heat. By releasing the exterior and clearing heat, the absence of sweat and labored breathing can be addressed. Therefore, the formula can be applied whether or not there is the presence or absence of sweat. Upon clinical application, if the patient does not sweat but has mild aversion to cold with body aches, the use of shí gāo needs to be light, either at a ratio of 3 : 5, or one can add dispersing medicinals to help release the exterior. If there is sweat and excessive heat, increase the amount of shí gāo and add lung-clearing medicinals. The ratio of shí gāo to má huáng will increase to either 4 : 1 or 5 : 1. In short, we should not be restricted by the

“presence of sweat and labored breathing’as long as we can carefully analyze the reason for the absence or presence of sweat. The ratio of má huáng to shí gāo can be adjusted appropriately, or the appropriate medicinals can be added to the formula. If the medicinals match the pattern, the effect will be instantaneous.

Formula Applications 1. Essential pattern differentiation Má Xìng Gān Shí Tāng is used to treat patterns of unresolved external pathogens complicated by pathogenic heat obstructing the lung with labored breathing and cough. Due to the fact that shí gāo is double the weight of má huáng, its action is more on clearing heat and diffusing the lung, and much less on inducing sweat. This clinical pattern is marked by:

2. Modifications

3. Modern applications The formula may be used in the following biomedically defined disorders showing signs and symptoms of unresolved external pathogens

complicated by pathogenic heat obstructing the lung: common cold, upper respiratory infection, acute bronchitis, bronchopneumonia, lobar pneumonia, bronchial asthma, and measles complicated by pneumonia. 4. Cautions and contraindications This formula is not appropriate for cough and labored breathing caused by wind-cold with phlegm-heat obstruction.

Comparison & Contrast Má Huáng Tāng vs. Má Xìng Gān Shí Tāng

Associated Formulas Yuè Bì Tāng (Maidservant From Yue Decoction, 越婢汤) [Source]

Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals. The decoction should be taken warm. [Actions] Induces sweat and promotes urination. [Applicable Patterns] Wind edema complicated by heat. Symptoms include: aversion to wind, general edema, absence of thirst, spontaneous sweating without a high fever, and a superficial pulse. Yuè Bì Tāng and Má Xìng Gān Shí Tāng both use má huáng to diffuse lung qi and release the exterior, and shí gāo for clearing and draining internal heat. The former is indicated for wind edema complicated by heat pattern showing general edema. It utilizes a large amount of má huáng and combines shēng jiāng to induce sweat for the removal of superficial dampness, diffuse the lung to free and regulate waterways, and promote urination to guide out water. It includes dà zăo and gān căo to boost qi and fortify the spleen by consolidating the earth in order to restrain water. Má Xìng Gān Shí Tāng, however, is indicated for unresolved exterior pathogen causing cough and labored breathing caused by pathogenic heat accumulation in the lung. As a result, it contains the combination of má

huáng and xìng rén used to diffuse and descend lung qi, relieve cough, and calm labored breathing.

Case Studies 1. Cold damage Zhong, living somewhere on Sheng Mu Yuan Road, suffered cold damage for seven days with fever, absence of sweat, slight aversion to cold, general body ache, and difficulty to spit out phlegm. These were signs of obstructed lung qi. The yellow phlegm indicated that the exterior pathogen already had transformed to heat. He was prescribed Má Huáng Xìng Rén Gān Căo Shí Gāo Tāng with fú píng. It was composed of má huáng 3 qian, xìng rén 5 qian, shí gāo 4 qian, qīng dài 4 fen, shēng gān căo 3 qian, and fú píng 3 qian. At the second visit he reported that after taking Má Xìng Gān Shí Tāng plus fú píng, the sweat discharged and the fever moderately decreased. However, the cough remained and spitting out phlegm was still inhibited. There was chest and abdominal pain and the pulse was still, superficial, and tight. The treatment method, to promote sweat, remained unchanged. A new prescription composed of má huáng 3.5 qian, gān căo 2 qian, shí gāo 6 qian, bò he 1 qian, xìng rén 4 qian, jié gĕng 5 qian, yì yĭ rén 1 liang, chuān pò 2 qian, and zĭ sū yè 5 qian was prescribed. Upon ingestion, a light sweat was induced and the fever was eliminated. However, the chest, back, and abdomen still had mild, unfixed pain. Then, after the third day, the disease was completely resolved as the patient got out of bed as normal. 1 2. Spring warmth Zeng, a 20-year-old male from Nan Jie, Hui Li Town, Sichuan, contracted spring warmth in February, 1924. He was sick for three days with a superficial rapid pulse, fever, slight aversion to cold, headache, body ache,

dirty complexion, red and dry lips, a white and dry tongue coating, a crimson tongue tip, thirst for cold drinks, and scanty brown urine. The disease was due to spring warmth causing interior heat obstruction with pathogens fettering the exterior to form a pattern of exterior cold and interior heat, for which Má Xìng Gān Shí Tāng is indicated. His formula was composed of má huáng 12 g, shí gāo 30 g (wrap with cloth and smash), xìng rén 10 g, and gān căo 6 g. Not long after he completed the first dose, he had a profuse sweat, his pulse calmed, his fever cooled, and he was cured in a snap.2 3. Summerheat 1 Cao Ying-fu. Records of Experiments with Classical Formulas 经⽅实验录. Shanghai: Shanghai Scientific and Technical Publishers; 1979. p. 24-25. 2 Wu Pei-heng. Wu Pei-heng’s Case Records 吴佩衡医案. Kunming: Yunnan People’s Publishing House; 1979. p. 18-19.

Liao, a 30-year-old male, originally from Hui Li Town of Sichuan and currently a resident at Eight Hai Chao Xiang Lane, Kunming, Yunnan. He went to visit the countryside for an outing on May 16th, 1928. It was a hot summer day and he had an aversion to the heat. He craved cool weather so much that he took off his clothes whenever there was the breeze. Later that same evening, he felt so hot like he was sweltering and had a desire for water, general fatigue, lassitude, and discomfort. He then developed a mild aversion to cold, dizziness, headache, soreness, heaviness, and pain over the body and limbs. He was generally in very good health and did not get sick often, therefore he did not pay much attention to it of this time. However, his body temperature increased drastically not long afterward. He had a high fever, irritation, thirst, favored cold drinks, had scanty dark urine, and a loss of appetite. He was given an injection under Western medical care with no effect, and then finally went to see the author three days after the initial onset. His pulse was superficial, wiry, and rapid, and his face and lips were

red and dry. He had a red tongue with a very dry coating, felt very warm all over his body surface, had absence of sweat, rapid labored breathing, and was moaning. All of these were the result of summer-heat damaging yin and obstruction of pathogenic heat fettered by exterior wind-cold leading to a pattern of exterior cold and interior heat. The proper method was to simultaneously release the exterior and interior. [Zhang] Zhong-jing’s Má Huáng Xìng Rén Gān Căo Shí Gāo Tāng was prescribed to release the exterior with its acrid-cool medicinals [and clear internal heat]. It was composed of shēng má huáng 12 g, shēng shí gāo 24 g (smashed and wraped with cloth), xìng rén 10 g, and gān căo 10 g. After one dose, he was sweating as if he had a bath, the fever reduced, the pulse calmed, the body cooled down, and his headache and body aches dissipated. Although his exterior pathogen was resolved, there was still interior residual heat to be cleared, indicated by the fact that he still preferred cold drinks. The second prescription was Rén Shēn Bái Hŭ Tāng combined with Shēng Mài Săn to foster original yin and clear the remaining heat. 1 Comments: All three of the cases above were due to patterns of exterior cold and interior heat. The use of Má Xìng Gān Shí Tāng to effectively induce sweat and alleviate the disease, verified the exterior-releasing and interior-clearing actions of the formula. The cases reveal three keys to successfully applying formulas. The first one is precise pattern differentiation. The signs of the pattern are mild aversion to cold, absence of sweat, and body aches. The interior symptoms included a fever, cough, labored breathing, yellow phlegm, red face, thirst, and a red tongue. These were due to wind-cold fettering the exterior complicated by interior obstruction of pathogenic heat.

The second key is dosing the medicinals properly. In all three situations the ratio of má huáng and shí gāo (3 : 4, 1 : 2.5, and 1 : 2) was adjusted appropriately. This allowed má huáng to induce a sweat and release the exterior without being overly restricted by an inappropriate amount of cold shí gāo. The third key is ingenuity. The third case utilized the formulas to treat patterns of summerheat with signs and symptoms of exterior cold and interior heat with considerable ingenuity. Some people think that má huáng, guì zhī, and the like are prohibited in the summer. In fact, it really depends on the case. The pattern is interior heat fettered by exterior cold. How can the exterior be released without má huáng? Another miraculous point was the twist of the second formula, a combination of Rén Shēn Bái Hŭ Tāng and Shēng Mài Săn, used to foster yin and clear heat with prompt efficacy.

Chái Gé Jiĕ Jī Tāng 柴葛解肌汤Bupleurum and Pueraria Muscle-Resolving Decoction Source Text Six Texts on Cold Damage Shāng Hán Liù Shū, 伤寒六书)

Formula Ingredients

1 Wu Pei-heng. Wu Pei-heng’s Case Records 吴佩衡医案. Kunming: Yunnan People’s Publishing House; 1979. p. 21-22.

Preparation and Administration Add 3 slices of shēng jiāng and 2 whole pieces of dà zăo to the rest of the formula and prepare it as a decoction. It should be taken warm.

Formula Indications

This formula is indicated for externally contracted wind-cold that has become constrained and transforms into a heat pattern. The signs and symptoms include gradually reducing aversion to cold and increasing body heat, absence of sweat, headache, eye pain, dryness of the nose, vexation, insomnia, dry throat, impaired hearing, orbit pain, a thin yellow tongue coating, and a superficial, slightly surging pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is the result of unresolved wind-cold constrained within taiyang that has transformed into heat. It then transmits to yangming, spreads further to shaoyang, and eventually affects all three yang channels. Aversion to cold, absence of sweat, and headache are due to unresolved wind-cold constrained in the taiyang. The pathogen, after penetrating into the interior, heats up and attacks the yangming and shaoyang. It causes eye pain, nose dryness, orbit pain, dry throat, and impaired hearing. These symptoms are related to how the two channels transverse: Yangming originates from both sides of the nose, goes up to the root of nose, passes through the orbits, and travels down. Shaoyang winds its way behind the ears, enters, comes out in front of them, passes through the cheeks and reaches the infra-orbital area. In addition, the superficial and slightly surging pulse is evidence of the exterior pathogen and excessive interior heat. The appropriate treatment is to release the flesh with acrid-cool medicinals and clear interior heat.

Formula Actions Releases the flesh and clears heat.

Formula Analysis

Continued

Unique Combination Features First, this formula employs both warming and clearing methods. However, it places more focus on clearing heat using acrid-cool medicinals. Second, it treats both the exterior and interior simultaneously by scattering, draining, venting, and dissipating. These are the differences that distinguish Chái Gé Jiĕ Jī Tāng from other acrid-cool exterior-releasing formulas indicated for patterns of exterior wind-heat.

Further Clarification In regards to the indications and combinations

Three-yang channel combined illness, for which the formula is indicated, has the primary characteristic of heat obstructing the yangming. Due to the unresolved taiyang wind-cold, residual heat somewhat impacts the shaoyang. Although all three yang channels need to be treated simultaneously, the main channel targeted is the yangming. The taiyang and shaoyang are also addressed, but to lesser extent. Gé gēn is excellent for venting and dissipating heat obstructing the yangming. Bái zhĭ, which releases the exterior with acrid-warm, also enters yangming. It is capable to dissipate exterior pathogens from the yangming with its properties. As a key ingredient to clear pathogenic heat in the yangming, shí gāo is used in this combination to thoroughly clear heat. At the same time, qiāng huó, with its tropism to taiyang, releases the exterior to dissipate cold on the surface of the taiyang channel. Chái hú enters the surface of shaoyang while huáng qín clears the heat in the fu-organ of the gallbladder channel, so that together the two vent and release pathogenic heat from the shaoyang. The combination of the above takes care of all three yang channels in one formula, while maintaining its focus on the yangming.

Formula Applications 1. Essential pattern differentiation Chái Gé Jiĕ Jī Tāng is commonly applied to treat the pattern of unresolved taiyang wind-cold that has entered the interior and transformed into heat attacking the yangming in its early stages or when all three yang channels are affected. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of the constrained externally contracted wind-cold that has transformed into internal heat: common cold, flu, gingivitis, and acute conjunctivitis. 4. Cautions and contraindications This formula is inappropriate for patterns where an exterior taiyang pathogen has penetrated into the interior, because it may guide the pathogen deeper. It is also not appropriate for patterns of internal heat from yangming bowel excess, i.e., dry, constipated, and blocked stool.

Associated Formula Chái Gé Jiĕ Jī Tāng (Bupleurum and Pueraria Muscle-Resolving Decoction, 柴葛解肌汤) [Source] Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. For vexation: add dàn zhú yè 10 pieces (3 g); for delirious speech: add shí gāo 3 qian (12 g). [Actions] Releases the exterior and clears heat. [Applicable Patterns] Exterior contraction of wind-heat with excess internal heat. Symptoms include: no aversion to cold, thirst, a yellow tongue coating, and a superficial, scattered pulse. Cheng’s Chái Gé Jiĕ Jī Tāng, the associated formula, is indicated for externally contracted windheat with excessive internal heat. It removes qiāng huó, bái zhĭ, and jié gĕng to avoid fluid damage because their acrid, warm, fragrant, or dry nature may stimulate heat. Simultaneously, it adds zhī mŭ, bèi mŭ, mŭ dān pí, and shēng dì to clear heat, cool blood, and nourish yin. It is obvious that Cheng’s version focuses more on clearing the interior while Tao’s more on releasing the surface.

Case Studies 1. Fever He, an 8-year-old boy, had his initial visit on November 3rd, 2000. He had aversion to cold, absence of sweat, fever of 38.2°C (100.76°F),

headache, general aches, cough, and clear nasal discharge. He was treated with paracetamol and i.v. of ampicillin. Previously he had a sweat that eliminated the fever; however, the fever recurred. Examination revealed lassitude, red face and lips, reduced aversion to cold, increased fever at 38.8°C (101.8°F), headache, body ache, bitter mouth, dry throat, and thirst with a desire for water. His stool was dry and had bowel movements only once every other day. His tongue was red with a yellow coating, and his pulse was wiry, slippery, and rapid. His pattern was combined three yang illness, and therefore the treatment method was to release the flesh and clear heat. The formula used was a modified [Tao’s] Chái Gé Jiĕ Jī Tāng composed of chái hú 10 g, gé gēn 10 g, huáng qín 6 g, bái sháo 10 g, jié gĕng 10 g, gān căo 6 g, qiāng huó 6 g, bái zhĭ 6 g, shí gāo 30 g, dà huáng 3 g, and lián qiào 10 g. He was prescribed two doses to be prepared as a decoction. Each dose was to be cooked twice and the yields mixed together and taken three times daily. On his second visit his temperature was normal during the day and 37.3°C (99.14°F) at night. His bowel movements became normal and the other symptoms reduced. Dà huáng was removed from the previous prescription, and 12g of xuán shēn was added. He took three doses and completely recovered.1 Comments: The pattern in this case was “cold wrapped around heat”. All three yang were involved with symptoms of reducing aversion to cold and increasing fever, headache, body aches, red face and lips, thirst with the desire for water, bitter mouth, and dry throat. Chái Gé Jiĕ Jī Tāng was prescribed in order to dissipate taiyang cold, vent yangming’s heat, and scatter shaoyang pathogen. Because the formula and pattern matched, the effect was great. 2. Trigeminal neuralgia

A 22-year-old female patient had trigeminal neuralgia for five years. While it would occasionally feel better, it was protracted and would never completely dissipate. Examination revealed unbearable burning pain on the left side of her head and face that would occasionally alternate with a headache. Recently, it was flaring more frequently and was accompanied by dizzy vision, dry nose, tinnitus, bitter mouth, thirst, vexation, and irritation. Her tongue was dry with a normal coating, and her pulse was wiry, tight, and rapid. The pattern was wind toxins invading the yangming sinews with constrained heat affecting taiyang and shaoyang. Modified Chái Gé Jiĕ Jī Tāng was prescribed, composed of chái hú 6 g, gé gēn 6 g, huáng qín 6 g, bái sháo 15 g, shí gāo 30 g, qiāng huó 12 g, bái zhĭ 12 g, jié gĕng 12 g, gān căo 10 g, dà zăo 10 g, wú gōng 2 whole pieces, dì lóng 20 g, and quán xiē 6 g; prepared as a decoction. By her second visit, after taking three doses, the heat and pain were mostly reduced with only a slight warm sensation in her face. Her pulse was wiry and slow. She was prescribed five more doses with shí gāo removed and huáng qí 30 g added. By her third visit, her pain was relieved with only occasional facial muscle soreness. She was instructed to take one dose of the same prescription every other day for a half month. Her case was followed for a year with no recurrence noted.2 1 Wang Gui-hua. A Sample Case of Child with Exterior Contraction and Interior Heat Pattern ⼩ ⼉外感发热证治举隅. Heilongjiang Journal of Traditional Chinese Medicine. 2002; 3: 43. 2 Wang Chun-cai. Extended Application of Chái Gé Jiĕ Jī Tāng 柴葛解肌汤的引申应⽤. Journal of Sichuan Traditional Medicine. 1992; 12: 21.

Comments: Trigeminal neuralgia is categorized as hemilateral head wind in Chinese medicine. Historically, it was believed it is caused by the shaoyang being attacked by wind. However, since the cheeks are where the yangming channel is distributed, it actually has a closer relation to the yangming. This was a case of exterior contraction of wind toxin lingering in the yangming channel and collateral, which transformed into heat due to

prolonged oppression, and spread to affect the taiyang and shaoyang. Chái Gé Jiĕ Jī Tāng was able to clear and drain the heat with acrid-cool medicinals, release the flesh, and soothe the channels. Adding quán xiē, wú gōng, and dì lóng to track and expel wind, unblock collaterals, resolve toxin, and relieve bì enabled the formula to cure this chronic and refractory illness.

Fáng Fēng Tōng Shèng Săn 防风通圣散 Ledebouriella Sage-Inspired Powder Source Text Formulas from the Discussion Illuminating the Yellow Emperor’s Basic Questions-Volume Three (Huáng Dì Sù Wèn Xuán Míng Lùn Fāng, 黄帝素 问宣明论⽅·卷3)

Formula Ingredients

Preparation and Administration

Take 6g of the powder per dose, add three slices of shēng jiāng, and boil down with water. It should be taken warm. It can also be prepared as decoction with the medicinals proportionally reduced in amount according to the original formula.

Formula Indications This formula is indicated for patterns of heat accumulation causing both exterior and interior excess. The signs and symptoms include aversion to cold, high fever, dizziness, vertigo, red and painful eyes, bitter and dry mouth, throat discomfort, chest and diaphragm pĭ and oppression, cough, vomiting, labored breathing, fullness, thick and sticky nasal discharge and saliva, constipation, dark urination, difficult urination, a yellow and greasy tongue coating, and a rapid forceful pulse. It also treats sores, ulcerations, furuncles, abscesses, intestinal wind, hemorrhoids, fistula, red nose, and urticaria.

Analysis of Fundamental Pattern Pathogenesis This formula is designated for external wind contraction complicated by internal heat accumulation, forming a pattern of exterior and interior excess. When wind-heat pathogens attack the lung wei, there will be aversion to cold, high fever, throat discomfort, cough, and labored breathing. If the wind-heat attacks the head, symptoms such as dizziness, vertigo, and red painful eyes appear. If the heat accumulates in stomach and intestines, it blocks the qi movement manifesting thirst, chest pĭ, constipation, and dark urine. When wind heat accumulates and depresses qi and blood, it leads to sores, ulcerations, furuncles, abscesses, intestinal wind, hemorrhoids, fistula, red nose, and urticaria. The appropriate treatment for this pattern is to scatter

and dissipate wind-heat in order to release the exterior, drain heat, and purge dry feces to remove interior excess.

Formula Actions Scatters wind, releases the exterior, drains heat, and promotes defecation.

Formula Analysis

Unique Combination Features The formula blends the sweating, purging, clearing, and supplementing methods. It has the primary actions of scattering, dissipating, clearing and draining, so inducing sweat does not damage the exterior and clearing and purging do not damage the interior.

Formula Applications 1. Essential pattern differentiation This formula is indicated for patterns of concurrent exterior and interior excess. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of concurrent exterior and interior excess due to the accumulation and obstruction of wind-heat:

common cold, hypertension, migraine headache, obesity, chronic constipation, acute conjunctivitis, senile pruritus, facial rosacea, and alopecia areata. 4. Cautions and contraindications This formula has a drastic ability to induce sweat and purge. It can therefore cause damage to fetal qi. Therefore, people with a weak constitution or pregnant women should take extra caution and consult a qualified Chinese medical doctor prior to its use.

Case Studies 1. Vertigo Xu, a 56-year-old female, came for her initial visit on September 15th, 2006. She had dizziness for ten years with a history of hyperlipemia and was diagnosed with vertigo in her local healthcare station. She was given dān shēn and Mài Luò Níng (note by translator: a product of China with the literal meaning of Vessels and Collateral Tranquilizer) intravenously, and her condition improved and some days were better than others. Thereafter, she came to visit the Chinese medicine hospital. Upon examination, she was found to have a plump figure, flushed face, dizziness and vertigo, thirst, dryness of the tongue, aversion to cold, vexation, insomnia, lack of appetite, constipation with bowel movement every other day, a red tongue with a yellow greasy coating, and a wiry, slippery pulse. Her total cholesterol measured 6.6mmol/L and all other indices measured normal. The diagnosis after a comprehensive analysis of the four examinations was vertigo due to the accumulation of wind-heat and obstruction of abdominal qi. The proper treatment method was to scatter wind, clear heat, and purge interior accumulation. She was prescribed modified Fáng Fēng Tōng Shèng Săn

composed of shēng shí gāo (decocted first) 30 g, jiāo shān zhā 30 g, huá shí 30 g, chuān niú xī 30 g, bò he (decocted later) 6 g, zhì má huáng 6 g, jīng jiè 6 g, fáng fēng 6 g, huáng qín (plain stir-fried) 10 g, shēng zhī zĭ 10 g, dāng guī 10 g, zhì dà huáng 10 g, yì mŭ căo 10 g, chuān xiōng 10 g, and máng xiāo (infused) 10 g. Her bowel movements became normal and her vertigo reduced after taking five continuous doses. Máng xiāo was removed from the previous formula and she was instructed to take nine more continuous doses. Her dizziness and vertigo gradually disappeared, the taste in her mouth became normal, and bowel movements slightly loose. Therefore, zhì dà huáng was removed, shēng shí gāo and huá shí were reduced to 20 g on her third prescription. She took another continuous six doses, and all her symptoms were eliminated. She was then advised to take patent formulas intermittently for three months. As a result, her weight was obviously reduced and the blood lipids examination measured her cholesterol at a normal level. Her case was followed for three years and her vertigo never recurred. 1 Comments: The major symptoms in this case were dizziness, vertigo, aversion to cold, flushed face, thirst, tongue dryness, constipation, red tongue, yellow greasy coating, and a wiry, slippery pulse. The disease mechanism was excess yang heat accumulation that formed a pattern of exterior and interior excess. Therefore, Fáng Fēng Tōng Shèng Săn was used to clear heat, release the exterior, remove dampness, and unblock abdominal obstruction. Dampness obstruction and heat oppression blocked circulation of the blood, channels, and vessels. Therefore, medicinals such as shēng shān zhā, chuān niú xī, and yì mŭ căo were added to invigorate blood and unblock the collaterals. Modern Chinese medical pharmacology research has proved that these medicinals are able to lower blood lipids. In this case, their effect helped the patient to lose weight. Overall, the formula was able to

resolve problems manifesting in the exterior, interior, qi, blood, and all three jiao by addressing the root cause. Thereby, the vertigo was resolved. 2. Allergic asthma 1 Chu Cheng-hai, Yang Le-le. Sample Clinic Application of Fáng Fēng Tōng Shèng Săn 防风通 圣散临证运⽤举隅. Jilin Journal of Traditional Chinese Medicine. 2008; (1): 51.

Bi, a 22-year-old female student had her initial visit on June 9th, 1988. Beginning in March, she suffered chest oppression and rapid breathing, while she was spending a month in Singapore for studies. But she had not been able to study normally due to the condition. She was then diagnosed with allergic asthma and stayed in a hospital for one month without any obvious improvement. Thereafter, she returned to China to seek medical assistance. Again, she was in a hospital without progress. Then, a friend of hers introduced her to see Dr. Zhao. Upon examination she had a puffy and tarnished face, fullness and oppression on the chest and diaphragm, rapid short coughing and breathing, white, sticky and thick phlegm difficult to expectorate, distention in the middle abdomen, poor appetite, vexation, poor sleep, constipation, amenorrhea for three months, a dark red tongue with yellow greasy coating, and a soggy, slippery and rapid pulse. The pattern was excess phlegmdampness constitution with the constrained accumulation that transformed into heat. The first step of the treatment was to dissolve phlegm, descent counterflow, drain the lung [fire], and calm labored breathing. She was prescribed Fáng Fēng Tōng Shèng Săn composed of jīng jiè 6 g, fáng fēng 6 g, má huáng 2 g, lián qiào 10 g, zhī zĭ (plain stir fried) 6 g, huáng qín 6 g, jié gĕng 10 g, zĭ sū zĭ 10 g, lái fú zĭ (plain stir fried) 10 g, zhè bèi mŭ 10 g, and dà huáng 1 g. Seven doses were prescribed to be prepared as a decoction for oral consumption. By her second visit on June 16th, her symptoms were alleviated after taking the formula. She had smooth bowel movements, improved mental vitality, and increased appetite.

However, her period still did not arrive. Seven doses of the previous prescription with addition of xuán fù huā 10 g, dāng guī 10 g, and chuān xiōng 10 g were prescribed to be taken as an a decoction for oral consumption. By her third visit on June 23rd, her period arrived with a moderate amount after taking the formula. She had calm breathing, and elimination of her other symptoms. Her tongue was red with a thin, white coating, indicating that her dampness was gradually dissolving and heat oppression was gradually clearing. The prescription was modified by removing zĭ sū zĭ and lái fú zĭ, and adding bái zhú 10 g and gān căo 10 g to the previous formula. Seven doses were prescribed to be prepared as a decoction. After completing them, her facial complexion improved. She was then given about twenty more doses and her previous situation did not recur. Therefore, she switched to taking Fáng Fēng Tōng Shèng Săn in the form of water pills, 6g each dose, twice daily to moderate the efficacy. Her condition did not recur for more than a month. She went back to school with forty packs of Fáng Fēng Tōng Shèng Wán and modified Băo Hé Wán. Later, her mother passed a message that she did not have any further onset of asthma or amenorrhea, and the rest of her physical condition was normal.1 Comments: Allergic asthma is a common disease that affects teenagers and juniors more than other groups clinically. It is often caused by the invasion of the six external pathogens, improper diet, emotional factors, or laborious work. In this case, the patient had a weak constitution with phlegmdampness. In her case, she traveled a long distance to South Asia where the climate was damp. In addition, as seafood contributes to a good portion of the local diet, there was strain on her spleen (earth property) that caused it to fail to govern food transportation and transformation. As a result, damp turbidity accumulated and became stagnant for a long time. It transformed into heat and developed binding phlegm, obstructed the lung,

and then the lung failed to purify and descend triggering her laborious breathing. The formula prescribed in this case applied má huáng, jīng jiè, fáng fēng, and jié gĕng to diffuse the lung and calm labored breathing. Shān zhī and huáng qín were used to drain the excess heat in the lung and the stomach. Huá shí was used to clear heat and resolve dampness. Dà huáng was used to unblock the bowel, promote digestion, and guide out the stagnation. Sháo yào and dāng guī were used to invigorate blood and remove stasis. The main symptoms in her case were cough and labored breathing complicated by her constitution of excess phlegm-dampness. Therefore, zĭ sū zĭ, lái fú zĭ, and zhè bèi mŭ were added to descent the lung qi and dissolve phlegm turbid. With the formula corresponding exactly to the disease pattern, the treatment effect was effective. To reinforce the treatment effect, the combination of Fáng Fēng Tōng Shèng Săn and modified Băo Hé Wán were prescribed to harmonize the stomach, fortify the spleen, clear heat, and dissolve dampness.

Shēng Má Gé Gēn Tāng 升麻葛根汤Cimicifuga and Pueraria Decoction Source Text 1 Yang Lian-zhu, Wang Jun. Zhao Shao-qin’s Sample Clinical Application of Fáng Fēng Tōng Shèng Săn 赵绍琴临床运⽤防风通圣散经验举隅. Chinese Journal of Traditional Chinese Medicine and Pharmacy. 2001; (1): 49.

Formulas from the Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Take 9 g of powder per dose and boil down to make a beverage. It should be taken warm, with no fixed schedule, until the pathogenic qi is resolved and the body cools down. It can also be prepared as a decoction with amounts proportionally reduced.

Formula Indications This formula is indicated for the initial stage of measles. Signs and symptoms include rashes unable to express, body heat, headache, cough, red

eyes, tearing, thirst, a red tongue with a thin, dry tongue coating, and a superficial, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis Measles attack when a child has accumulated heat in the lung and the stomach and it is further complicated by the contraction of an epidemic pathogen. If the child were not treated carefully at the initial stage, he may be affected by other external pathogens that block the exterior flesh and further lead to an inability to express or an unsmooth eruption of the rashes. If there is accumulated heat in the lung and the stomach and attacks of external pathogens, the zheng qi struggles with the pathogen and the lung qi fails to purify and descend. Therefore, there will be symptoms of lung wei at the initial stage, such as fever, headache, cough, red eyes, tearing, and a superficial, rapid pulse. Since heat causes fluid damage, there will be thirst and a red tongue with a dry tongue coating. For measles, eruption is favorable over moving inward to the interior. For incomplete expression of the measles, the treatment should promote the eruption of the rash. Concurrently, because there is accumulated heat, it is proper to clear heat and resolve toxins simultaneously.

Formula Actions Releases the flesh and promotes complete eruption of rashes.

Formula Analysis

Further Clarification In regards to the choice of sháo yào The source text did not specify if chì sháo or bái sháo should be used in this formula since there was no such distinction made for sháo yào in the Song Dynasty. Most medical professionals, such as Wang Ang, Wang Tailin, and Fei Bo-xiong, claimed it was bái sháo while analyzing or commenting on this formula. A few experts claimed it to be chì sháo while analyzing it such as Wu Kun. Is it chì sháo or bái sháo in this formula? Chì sháo is bitter-cold and enters the blood level. It is able to clear and resolve heat toxins in the blood vessels, clear heat, and cool and invigorate the blood. It is therefore good to promote rashes and dissolve toxins. On the contrary, bái sháo is astringent; and therefore, not beneficial for promoting the eruption of measles towards the exterior. Based on this, we think that chì sháo is more appropriate for measles and other diseases that cause rashes. However, for treating dysentery chì sháo, bái sháo, or their combination is proper because bái sháo has the effect to alleviate urgency and relieve pain while chì sháo can be used to cool and invigorate blood.

Formula Applications

1. Essential pattern differentiation This is a fundamental formula used to treat the incomplete eruption of measles or prior to its presence. This clinical pattern is marked by:

● measles unable to express or insufficient eruption ● red tongue ● rapid pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of exterior pathogen blocking the surface with heat in the lung and the stomach: measles, varicella-herpes zoster, herpes simplex, diarrhea, and acute bacterial dysentery. 4. Cautions and contraindications Shēng Má Gé Gēn Tāng is prohibited when measles are thoroughly erupted, or the measles pathogen has invaded inward showing symptoms of rapid, short and heavy breathing with the shoulders moving up and down, and nasal flaring.

Associated Formula Zhú Yè Liŭ Bàng Tāng (Lophatherum, Tamarisk and Arctium Decoction, ⽵叶柳蒡汤) [Source] Extensive Notes on Medicine from Xian Xing Studio (Xiān Xĭng Zhāi Yī Xué Guăng Bĭ Jì, 先醒斋医学广笔记) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. For people with severe condition, add shí gāo 5 qian and nuò mĭ 1 fistful. [Actions] Promotes complete eruption of rashes, releases the exterior, clears heat, and promotes fluid production. [Applicable Patterns] Initial stage of acute rashes that cannot erupt. Symptoms include: cough, labored breathing, stuffy nose with nasal discharge, light aversion to cold, severe fever, vexation, irritability, sore and swollen throat, dry lips, thirst, a thin, yellow tongue coating, and a rapid, superficial pulse.

Both Shēng Má Gé Gēn Tāng and Zhú Yè Liŭ Bàng Tāng are able to promote the eruption of rashes and clear heat. Therefore, they are indicated for measles at the initial stage when the rash has not yet erupted. The former is a fundamental formula used to treat measles that have not yet erupted. It has a weaker rash-promoting and heat-clearing effect. The latter is more commonly used to treat measles that are not able to erupt. It is stronger to promote eruption and clear heat. It also has fluidpromoting and thirstrelieving functions, so it is especially appropriate for measles unable to erupt in patterns where heat toxins accumulate interiorly and damage fluid.

Case Studies 1. Eczema A 23-year-old male factory worker had an initial visit on July 25th, 1986. The patient suffered from pruritus on the area of his scrotum and both interior sides of his thighs for a month, accompanied by scattered, riceshaped papules. His previous treatment was ineffective and his condition was worse for the past two days. When he came for his visit, the pruritus was unbearable, with clustered papules, scratch marks, and some erosive effusion with an unclear border. The pattern was damp-heat in the blood level and wind-heat at the skin and flesh; therefore, the proper treatment method was to clear heat, dissolve dampness, cool the blood, and scatter wind. The formula used was modified Shēng Má Gé Gēn Tāng composed of shēng má 10 g, gé gēn 10 g, bái sháo 10 g, gān căo 6 g, jīng jiè 15 g, fáng fēng 10 g, chán tuì 12 g, chì sháo 10 g, xuán shēn 15 g, zĭ căo 10 g, shēng dì 35 g, and dì fū zĭ 15 g. He was given ten doses, and instructed to take one per day as a decoction. The revisit twenty days later showed that all the symptoms disappeared. The case was followed for a year without recurrence.1

1 Gao Wei-jun. Treating 163 Cases of Eczema with Modified Shēng Má Gé Gēn Tāng 加味升麻 葛根汤治疗湿疹163例. Gansu Journal of Traditional Chinese Medicine. 1992; (4): 15.

Comments: Eczema is the result of wind-damp-heat obstructing the skin and flesh, saturating blood vessels. In modified Shēng Má Gé Gēn Tāng, shēng má enters the lung and stomach channels, releases the flesh, and vents the exterior. It combines dì fū zĭ to clear heat and resolve dampness, gé gēn, jīng jiè, fáng fēng, and chán tuì to scatter wind, release the flesh, and drive the pathogens out from the exterior level. Chì sháo, xuán shēn, zĭ căo, and shēng dì cool and nourish blood, and clear blood level wind-heat when combined with wind-scattering medicinals. Bái sháo harmonizes the ying level and gān căo resolves toxins. Naturally, the formula as a whole achieves the actions of clearing heat, resolving dampness, cooling blood, and scattering wind. 2. Acute bacillary dysentery A 41-year-old male had his initial visit on July 15th, 1985. He had chills all over his body for two days with abdominal pain and diarrhea. The diarrhea started as watery feces and developed into purulent, bloody, and muculant discharge excreted in small amounts ten times in a day. Other related symptoms were tenesmus, distended abdomen after meals, thirst without a desire to drink, and only a small amount of urine. Examination revealed 37.6°C (99.7°F), a red tongue, a white greasy tongue coating with some yellow areas, a soggy rapid pulse, tenderness on the lower abdomen (left side more severe), and hyperactive borborygmus. Lab tests measured WBC 12×109/L, 76% neutrophils, and 24% lymphocytes; microscopic exam of the feces sample showed mucus ++, RBC ++, and pyocytes +++. His condition was associated with damp-heat dysentery as defined in Chinese medicine, with the pattern as dampness more severe than heat. He was prescribed gé gēn 9 g, shēng má 9 g, chì sháo 9 g, gān căo 5 g, jīn yín huā

20 g, huáng lián 9 g, guăng huò xiāng 15 g, cāng zhú 9 g, mù xiāng 9 g, and jiāo shān zhā 30 g. He was instructed to avoid raw, cold, oily, and greasy food. After he completed one dose, the frequency of defecation was evidently reduced, and his body temperature returned to normal with an improved pulse. He took three more doses and all the symptoms were eliminated. Blood tests were normal and fecal microscopy exams were negative twice in a row.1 Comments: Acute bacillary dysentery is associated with diarrhea or epidemic dysentery. The cause and disease mechanisms are external contraction of toxic epidemic damp-heat or the intake of insanitary food damaging the spleen, stomach, and intestinal tract. Shēng Má Gé Gēn Tāng uses gé gēn and shēng má to release heat from the flesh and boost clear qi of the spleen and stomach to move upwards and stop diarrhea. Chì sháo cools and invigorates the blood while mù xiāng moves qi to dissolve obstruction. With blood moving, it resolves suppuration; however, when qi moves tenesmus can be dissolved. Huáng lián and jīn yín huā clear heat, resolve toxins, fragrant huò xiāng dries up dampness, and cāng zhú dissolves dampness. Shān zhā promotes digestion to relieve diarrhea, and gān căo harmonizes the center and eases the urgency. With all of the medicinals working together, the formula is able to resolve the exterior pathogen, remove damp-heat, and harmonize qi and blood. Therefore, the diarrhea can be addressed. Consequently, the diarrhea will cease as the disease is eliminated.

Section 3 Zheng-Enhancing ExteriorReleasing Formulas 1 Yang Jing-shan. Treating 50 Cases of Acute Bacillary Dysentery with Modified Shēng Má Gé Gēn Tāng 加味升麻葛根汤治疗急性细菌性痢疾50例. Journal of Sichuan Traditional Medicine. 1987; (7): 19.

Zheng-enhancing exterior-releasing formulas are appropriate for exterior patterns afflicting zheng qi deficient constitutions. Zheng qi deficiency is defined as insufficient qi, blood, yin, yang, or fluids. For these patterns, if a sweat-inducing method was used alone, not only would the sweat consume the already insufficient qi, blood, yin, yang, or fluids, but also the pathogens will not be expelled but rather would linger due to deficient zheng qi. Therefore, the correct treatment is to assist zheng and expel the pathogens at the same time so that sufficient zheng qi will help expel the pathogens. Consequently, some formulas in this category often combine exterior-releasing medicinals with qiboosting and yang-enhancing rén shēn, huáng qí, fù zĭ, and xì xīn in order to boost qi or assist yang to release the exterior. Representative formulas include Bài Dú Săn, Shēn Sū Yĭn, and Má Huáng Xì Xīn Fù Zĭ Tāng. Another subcategory combines materials to enrich yin and nourish blood such as yù zhú and shēng dì to enrich yin and nourish blood and release the exterior. Jiā Jiăn Wēi Ruí Tāng and Cōng Bái Qī Wèi Yĭn are representative formulas.

Bài Dú Săn 败毒散Toxin-Resolving Powder Source Text

Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Take 6g of the powder per dose, add 1 g of shēng jiāng and bò he to it and boil them together. It can be taken any time. Take it warm if the cold is more severe, and lukewarm if the fever is more serious. It can also be prepared as a decoction following the ratio of each ingredient in the original formula.

Formula Indications This formula is indicated for the pattern of externally contracted windcold-dampness. The symptoms are strong aversion to cold, high fever, headache, neck stiffness and pain, body soreness and pain, absence of sweating, stuffy nose, harsh voice, cough with phlegm, pĭ, and distressed

chest and diaphragm. The tongue is pale with a white coating, and the pulse is superficial and forceless upon pressing.

Analysis of Fundamental Pattern Pathogenesis This formula treats patterns of zheng qi deficiency with externally contracted wind-colddampness. Strong aversion to cold, stiff and painful head and neck, body aches, and an absence of sweat are signs of wind-colddampness attacking the surface of the flesh and lingering within the channels. The stuffy nose with a harsh voice, cough with phlegm, pĭ, and suppressed chest and diaphragm are symptoms of wind-cold invading the lung, blocking it, and causing the lung qi to fail to diffuse which further results in fluid accumulation transforming into phlegm. A white and greasy tongue coating, and a superficial pulse that is forceless with pressure are characteristic for deficient constitution contracted external wind-colddampness. The treatment should dissipate cold, remove dampness, and boost qi to release the exterior.

Formula Actions Dissipates cold, removes dampness, boosts qi, and releases the exterior.

Formula Analysis

Unique Combination Features This formula benefits the zheng qi and resolves pathogens simultaneously, and is focused on dispelling the pathogens. It also diffuses

the lung to dissolve phlegm and regulates qi and fluids. Yu Jia-yan of the Ming Dynasty treated external pathogens that had penetrated into the interior causing dysentery by scattering and dissipating the exterior pathogens. With the exterior zheng qi unblocked, interior obstructions, including dysentery, can be removed. This treatment method is referred to as “pulling the boat to counter the stream”[16].

Further Clarification 1. The combination of rén shēn with other medicinals The addition of a small amount of rén shēn to the wind-cold dispelling medicinals helps to boost qi and enhance zheng qi. Here is why this is necessary. If we only consider the removal of pathogens without replenishing zheng qi in a pattern of externally contracted pathogens in a qideficient constitution, the body will not have the strength to dispel the pathogens. Even with the temporary release of the exterior pathogen, it will later re-enter because insufficient zheng qi is not able to defend the body. Even though exterior-releasing medicinals direct pathogens outward, a zheng qi-deficient person who has contracted external pathogens will not have enough center qi to follow through. In a less serious situation, only a portion of the necessary sweating will be induced; in a more serious one, exterior pathogens can counter-attack because of the insufficient original qi and penetrate the interior. This leads to continuous fever and makes the situation more complicated. Therefore, rén shēn is added to increase the zheng qi in order to expel the pathogens and prevent them from entering the interior. Also, by using a small amount of rén shēn to supplement in a scattering formula, it prevents over-consumption of the original kidney qi. 2. “Rowing the boat against the stream” method

Yu Jia-yan often applied this method to treat patterns of dysentery caused by external pathogens that have penetrated the interior. This method was named “rowing the boat against the stream” by later generations. Dysentery is mostly the result of epidemic damp-heat toxins blocking the intestines where the disease progresses interiorly and downward. Therefore the treatment usually follows this momentum by clearing heat, removing dampness, and resolving toxins, and is accompanied by rectifying qi and blood and guiding out the obstruction. This is the common method used for treating dysentery. On the other hand, “rowing the boat against the stream” is an alternative method used to treat dysentery with a different cause, which is the inward invasion of an exterior pathogen, resulting in obstruction of the intestines and disharmony of qi and blood. Although the disease trend is inward and downward, the root cause of intestinal obstruction was the inward invasion of exterior pathogen. Therefore, by “counter”, it means to counter the tendency of the disease and the usual way of treatment. By utilizing exterior releasing medicinals, the inward pathogen is dispelled from the superficial level, as if pulling a boat upstream, and that is where the name comes from. By looking at the disease tendency, it seems this method goes opposite direction. However, by analyzing the disease mechanism, it actually follows the momentum, reflecting the difference between the superficial phenomenon and the essential nature of the disease.

Formula Applications 1. Essential pattern differentiation This is a commonly used formula to boost qi and release the exterior. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of the externally contracted windcold-dampness with qi-deficient constitution pattern: common cold, flu, bronchitis, allergic dermatitis, and eczema. 4. Cautions and contraindications Most of the medicinals in this formula are acrid, warm, aromatic, and dry. It is not applicable for yin-deficient patients with externally contracted pathogens, and is forbidden for dysentery caused by epidemic pestilence, damp-warmth, or intestinal accumulation of damp-heat.

Associated Formulas Jīng Fáng Bài Dú Săn (Schizonepeta and Saposhnikovia ToxinResolving Powder, 荆防败毒散) [Source] Numerous Miraculous Prescriptions for Health Cultivation (Shè Shēng Zhòng Miào Fāng, 摄⽣众妙⽅) [Ingredients]

[Preparation and Administration] Prepare it as decoction with 1.5 cups of water and boil down to 0.8 cup, and take while it is warm. [Actions] Induces sweat to release the exterior, dissolves furuncles and stops pain. [Applicable Patterns] Early stages of furuncles. Symptoms include: red swelling and painful furuncles, aversion to cold, fever, no sweat, thirst, a thin and white tongue coating, and a superficial, rapid pulse. Jīng Fáng Bài Dú Săn was developed based on Bài Dú Săn by removing rén shēn, shēng jiāng, and bò he and adding jīng jiè and fáng fēng.

Therefore, it is great for releasing the exterior and scattering pathogens, but not for boosting qi and enhancing zheng qi. Therefore, it is appropriate for treating furuncles and urticaria caused by externally contracted wind-colddampness without a pattern of zheng qi deficiency.

Case Studies 1. Concurrent malaria and dysentery Qian, living in Yun Xiu, Zhejiang Province, got wet in a sudden rain and started having chills and fever with a headache and body aches. In Qu Zhou, Zhejiang Province, it was customary to use the pulling and scraping technique in order to prevent the spreading of filthy disease. Therefore, they were applied first. Consequently, the patient did not visit a doctor until the third morning. Since he had alternating chills and fever, he was prescribed Xiăo Chái Hú Tāng plus digestionpromoting medicinals. Not only it was ineffective, but he also developed facial swelling and painful dysentery that frightened the whole family. Then, they invited Dr. Lei to see the patient. The pulse was superficial, slow, and wiry and the tongue coating was white with a lot of saliva. Both were signs of exterior wind-cold invading the interior, resulting in concurrent malaria and dysentery. Dr. Yu Jia-yan’s “pulling the boat to counter the stream” was the appropriate method with the addition of mù xiāng and hé yè added into the formula. After two doses, the chills and fever were immediately eliminated and the painful diarrhea reduced. 1 Comments: The patient in this case had alternating chills and fever as well as painful dysentery because of the exposure to the rain. Besides, he had aversion to cold, fever, a white tongue coating, and a superficial, slow, and wiry pulse. Thus, the pattern was inward invasion of the exterior colddampness, for which the proper treatment was “pulling the boat to counter

the stream” in order to scatter and dissipate the exterior pathogen. The patient had dysentery as the result of wind-cold fettering the exterior and blocking wei qi, causing the lung to fail to diffuse and descent, the intestinal tract became obstructed, and the qi and blood disharmonized. There were interior symptoms such as bloody, purulent diarrhea and tenesmus, as well as, exterior symptoms such as aversion to cold, fever, body ache, and stuffy nose. The use of Bài Dú Săn in this case reflected both critical principles of treating dysentery: eliminating the root cause and harmonizing qi and blood. Using acrid-warm scattering qiāng huó, dú huó, shēng jiāng, and bò he, it enabled the opening of the pores to resolve exterior wind-cold, and guide out the pathogens. Jīng jiè, qián hú, and zhĭ qiào were used to diffuse and descend lung qi in order to resolve interior qi obstruction. Chái hú and zhĭ qiào had the action to move qi and dredge stagnation, assisted by bloodinvigorating and pain-relieving chuān xiōng, was an application of the theory of “move blood to end purulent stool and regulate the qi to relieve tenesmus.”[17] The fact that there was an external contraction that progressed to dysentery shows that there was pre-existing spleen and stomach deficiency. The weak spleen and stomach failed to transform dampness. The dampness then blocked the middle jiao and the qi movement. When the external pathogen attacked, it obstructed the lung qi and went inward to invade the interior. This caused intestinal stagnation resulting in dysentery. That was why the formula included rén shēn, fú líng, and gān căo to fortify the spleen, percolate dampness, enrich zheng qi to expel pathogens and free the flow of body fluids. At the same time, it employed mù xiāng to help move qi and resolve stagnation, and hé yè to help fortify the spleen and dissolve dampness.

2. Recurrent furuncles 1 Lei Feng. Treatise on Seasonal Diseases 时病论. Beijing: People’s Medical Publishing House; 1980.p. 52.

Li, a 39-year-old government officer suffered from skin disease, with general furuncles affecting various areas all year around, and refractory tinea. His initial visit was in the spring of 1970. An examination revealed furuncles focused on the neck. There were also tinea, with unbearable itchiness, clustered over the waist, abdomen, and thighs. They adhered into palm-sized patches with yellowish exudation, for which long-term treatment had been unsuccessful. The author had previously prescribed him a variety of oral and externally used formulas with no effect. Although his pulse was a little rapid, it showed a certain level of weakness. There were teeth marks on the edge of his tongue. Bài Dú Săn was prescribed as a decoction and he was instructed to take several doses. The formula was composed of dăng shēn 9 g, fú líng 9 g, gān căo 6 g, zhĭ qiào 6 g, jié gĕng 4.5 g, chái hú 6 g, qián hú 6 g, qiāng huó 9 g, dú huó 6 g, chuān xiōng 6 g, bò he 1 g, and shēng jiāng 6 g. He came for another visit a half month later. Examination found his tinea was healing, so he was advised to take another half month of the same formula. The third visit found decrustation and new flesh appearing over the area of the tinea with reduced exudation. Therefore, he was instructed to take Bài Dú Săn on a long-term basis. After three months the tinea on the waist were not clearing; however, the furuncles had cleared and were not recurring. He was followed up until the winter of 1972 without any recurring furuncles, but the tinea on the waist still existed. 1 Comments: The patient in this case had unbearably itchy furuncles with yellowish exudation and teeth marks at the edge of his tongue as the result of wind-dampness intruding the exterior flesh causing qi and blood obstruction.

The furuncles broke out in one area after another along with a weak pulse indicating zheng qi deficiency. Dr. Yue used qiāng huó, dú huó, bò he, and shēng jiāng to dispel wind, remove dampness, and relieve itchiness. He used chái hú, zhĭ qiào, jié gĕng, and chuān xiōng to move qi and invigorate blood. Qián hú and fú líng were used to fortify the spleen and remove dampness, and dăng shēn, fú líng and gān căo to assist the zheng qi to expel pathogens. Since the medicinals corresponded to the disease pattern, it was able to reduce the furuncles and alleviate the tinea. According to Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴), “abscesses originate from fire toxins”[18], emphasizing that the condition was mostly a heat pattern. However, we should not too strict about this while facing specific clinical cases. In order to cure certain diseases, we need to design the treatment based on pattern differentiation. 3. Viral myocarditis Chi, a 19-year-old male patient came for his initial visit on April 6th, 2001. He contracted external cold five months ago with symptoms of aversion to cold, fever, stuffy nose, and clear discharge. He took some medicine to treat the common cold without any doctors’ advice. He did not improve and instead developed a high fever, palpitations, shortness of breath, and fatigue. The diagnosis from another hospital was viral myocarditis, and he was given i.v. of ATP, COA, huáng qí, and cì wŭ jiā as the treatment with a certain level of relief. However, he had frequent palpitations and shortness of breath that would get worse with cold, laborious work or stress, accompanied by dizziness, insomnia, dreamful sleep, spontaneous sweating, mild aversion to cold, a pale tongue, a thin and white coating, and a superficial, thin, wiry pulse. 1 China Academy of Traditional Chinese Medicine. Collection of Yue Mei-zhong’s Case Records 岳美中医案集. Beijing: People’s Medical Publishing House; 1978. p. 142-143.

He was diagnosed with palpitations, according the Chinese medicine. The pattern was wind-cold attacking the exterior with pathogens invading the heart. The appropriate treatment was to resolve toxins, vent the exterior, boost qi, and nourish the heart with a modified Bài Dú Săn. The formula was composed of shēng shài shēn 20 g, gān căo 15 g, fú líng 30 g, chuān xiōng 15 g, dú huó 15 g, qiāng huó 15 g, chái hú 15 g, zhĭ qiào 15 g, jié gĕng 10 g, huáng qí 10 g, and suān zăo rén 20 g. He was given three doses that were to be prepared as a decoction for oral consumption. He was advised to keep himself warm and not work too hard. Five days later, he noticed an obvious effect on the second day taking the formula including an absence of dizziness, rushed breathing, and palpitations. Generally speaking, he had good sleep. After completing three doses, all the other symptoms were eliminated except the inability to bear laborious work. No change was made to the formula because of its effectiveness. He continued with another six doses to reinforce the treatment efficacy.1 Comments: Although the patient had the illness for five months, the palpitations happened in conjunction with mild aversion to wind-cold, a pale tongue, a thin and white coating, and a superficial pulse. These were signs of a residual pathogen lingering from the external wind-cold attack. He also had dizziness, insomnia, dreamful sleep, lassitude, fatigue, and spontaneous sweating which are signs of deficient qi and blood that failed to nourish the heart. The appropriate treatment was to release the exterior by dispelling wind and dissipating cold, nourish the heart by boosting qi and calming the spirit. Therefore, modified Bài Dú Săn was prescribed to dispel wind, dissipate cold, and boost qi to assist zheng qi with qián hú removed since there was no phlegm, and huáng qí and suān zăo rén added to enhance the power of qi-boosting and spirit-calming.

Shēn Sū Yĭn 参苏饮Ginseng and Perilla Beverage Source Text Formulas from the Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration 1 Zhang Xiao-ming, Wang Gui-xiang. Four Cases of Using Bài Dú Săn to Treat Sophisticated Miscellaneous Diseases 败毒散治疗疑难杂症四则. Journal of Practical Traditional Chinese Internal Medicine. 2008; 22 (6): 94.

Prepare it as a decoction and add seven slices of shēng jiāng and one whole dà zăo. Take while it is warm with no fixed schedule.

Formula Indications

This formula is indicated for a pattern of qi deficiency with contraction of external wind-cold, complicated by interior phlegm-dampness. Signs and symptoms include aversion to cold, fever, absence of sweat, headache, stuffy nose, cough, white phlegm, distended and suppressed chest and abdomen, fatigue, lassitude, short of breath, dislike of speaking, a white tongue coating, and a weak pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is the result of spleen and lung qi deficiency with interior phlegm-dampness complicated by the contraction of wind-cold. Aversion to cold, fever, absence of sweat, headache, and a stuffy nose are symptoms of wind-cold fettering the exterior flesh, causing blockage of the lung system. Since phlegm-dampness obstructs the lung, the movement of qi is disturbed, so there is cough, white phlegm, distention and fullness in the chest and abdomen. Fatigue, lassitude, shortness of breath, no interest to talk, and a superficial pulse indicate qi-deficient external contraction. The appropriate treatment is to boost qi, release the exterior, rectify qi, and dissolve phlegm.

Formula Actions Boosts qi, releases the exterior, rectifies qi, and dissolves phlegm.

Formula Analysis

Unique Combination Features First, the formula uses dissipation in conjunction with supplementation so that the dissipation of the pathogen does not cause damage to zheng qi, and the pathogens are not retained due to supplementation. Second, it adjusts qi and fluids simultaneously. Thus, when qi circulated smoothly, the phlegm can be dissolved. When fluids move, qi flow is fluent.

Formula Applications 1. Essential pattern differentiation

This formula is commonly used for the pattern of qi deficiency with externally contracted windcold, complicated by interior phlegm-dampness. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders: common cold and upper respiratory infection when the patient shows signs of the qi deficiency with external contraction of wind-cold, complicated by phlegm-dampness.

Comparison & Contrast Shēn Sū Yĭn vs. Bài Dú Săn

Continued

Case Studies 1. Common cold Li, a 5-year-old boy, had a weak constitution and would typically sweat profusely. He often caught colds and coughs. Over the past few days, he had a fever, aversion to cold, clear nasal discharge, productive cough, relatively

severe headache, lassitude, weakness, pĭ and oppressed chest and abdomen, vomiting, nausea, distended painful abdomen, and no appetite. He had three to four bowel movements of loose stool every day that felt incomplete. Occasionally he woke up in the night. The diagnosis from one hospital was stomach flu. He was given child TMP-SMZ, child APC, and Xiè Bái Syrup (White-Draining Syrup, a patent medicine mainly used for clearing heat, dissolving phlegm and stopping cough), but the symptoms were not completely relieved. He was then taken to our hospital for help. His current symptoms include fever, body temperature of 37.6°C (99.7°F), slight chills, headache, cough, clear nasal discharge, full and distended abdomen, vomiting, nausea, lack of appetite, a yellowish facial complexion, lassitude, and fatigue. He had three bowel movements with loose stools and the feeling that they were incomplete. His tongue coating was white and greasy towards the root and his pulse was moderate and thready. His condition was due to his weak physical constitution and food retention, which was a concurrent exterior and interior sickness. The appropriate treatment was to boost qi, diffuse the lung, purge obstruction, and harmonize the center. Modified Shēn Sū Yĭn was prescribed composed of tài zĭ shēn 10 g, zĭ sū zĭ 10 g, zĭ sū yè 10 g, sāng yè 10 g, qián hú 10 g, jié gĕng 10 g, gé gēn 10 g, fú líng 10 g, shén qū 10 g, chén pí 3 g, bàn xià 3 g, and mù xiāng 3 g, mài yá 6 g, and shān zhā 6 g. It was to be prepared as a decoction and completed in three to four doses. After completing three doses, he sweat a great deal and the fever eliminated. The chills, headache, clear nasal discharge, full and distended abdomen, vomiting, and nausea all abated, and his appetite improved. He then had two bowel movements during the day, still felt weak, and coughed phlegm. His tongue coating and pulse remained unchanged. The pattern at that point was due to the residual pathogen and non-restored physical energy. The previous formula was used again, but with modifications. It was composed of dăng shēn 10 g, zĭ sū zĭ 10 g, fú líng 10g, chăo bái zhú 10 g,

qián hú 10 g, shén qū 10 g, zhì gān căo 3 g, jié gĕng 3 g, chén pí 3 g, bàn xià 3 g; 2 slices of shēng jiāng, and 5 whole dà zăo. The preparation and administration methods remained the same. All symptoms were relieved after three doses.1 Comments: The child had a cold for several days. Although he took Western medicine and a patent Chinese formula, he still had a fever, chills, headache, cough, and clear nasal discharge that were signs of residual windcold affecting the exterior. Concurrently, he had a full and distended abdomen, vomiting, nausea, lack of appetite, a yellowish facial complexion, fatigue, thin loose stool, and a white tongue coating that was greasy towards the root. The pattern was obviously due to qideficient external contraction with phlegm-dampness blocking the lung, complicated by the spleen failing to transport and transform. The treatment was to boost qi, release the exterior, diffuse the lung, dissolve phlegm, fortify the spleen, and harmonize the stomach. Therefore, Shēn Sū Yĭn with modifications was prescribed. On his first visit, zĭ sū zĭ and sāng yè were added to help diffuse and descend lung qi, dissolve phlegm, and relieve cough. At the same time, shén qū, mài yá, and shān zhā were added to promote digestion and harmonize the center so the spleen and stomach to regain their containing and transporting functions. By the second visit, sweating had been induced which relieved the exterior. Since there were still symptoms such as productive cough and fatigue, the previous formula was used with appropriate adjustments. Zĭ sū yè, gé gēn, and sāng yè were removed because the exterior was already released and tài zĭ shēn was replaced by dăng shēn to take care of the weak physical constitution of the child. By adding chăo bái zhú, it could fortify the spleen, dispel dampness, and stop diarrhea with the addition of shēng jiāng and dà zăo to enhance the spleen and harmonize the stomach.

Shēn Sū Yĭn is a formula that simultaneously treats the exterior and interior while considering both zheng qi and the pathogen. In this case, the formula was modified by adjusting its actions of dispelling the pathogen and reinforcing zheng according to the severity of the pathogen and the strength of the zheng qi. This is a great lesson worth learning by upcoming Chinese medical professionals. 2. Coronary heart disease 1 Wang Mei-lan. Experience of Applying Shēn Sū Yĭn to Treat Children Affected by External Contracted Diseases 参苏饮治疗⼩⼉外感疾患的体会. Journal of Tianjin College of Traditional Chinese Medicine. 2003; (2): 42.

A 68-year-old man suffered from palpitations, shortness of breath, left chest pĭ, and oppression due to laborious work. He would occasionally spit out small quantities of white, sticky phlegm that gave him relief after a short rest. Over the past a few days, the onsets of palpitations and chest pain have been frequent. He also had shortness of breath with activity, chest oppression, distention and fullness, profuse phlegm, and a poor appetite. His tongue was bleak with a white, greasy coating. His pulse was thready and a little slippery. An ECG indicated coronary arterial ischemia. He was diagnosed with palpitations and cardialgia. He had a pattern of qi deficiency, phlegm stagnation, blood stasis, and collateral obstruction. The treatment was to boost qi, eliminate phlegm, dissolve stasis, and unblock the collaterals. He was prescribed gāo lì shēn (decocted separately and blended with the decoction) 6 g, gé gēn 1 5 g, chuān xiōng 15 g, yù zhú 12 g, zĭ sū gĕng 10 g, chén pí 10 g, fă bàn xià 10 g, jié gĕng 10 g and shí chāng pú 10 g, zhĭ shí 6 g, guā lóu 20 g, dān shēn 20 g, and zhì gān căo 5 g. By his second visit his symptoms were significantly reduced after consuming three doses of the formula. Twenty-five doses of a subsequent formula was appropriately

modified and dispensed. All of his symptoms disappeared and the ECG measured normal. 1 Comments: This was a case of palpitations and cardiac pain resulting from binding phlegm and stasis due to qi deficiency and stagnation. When the patient worked too hard, qi was consumed. Qi deficiency led to qi stagnation which then caused phlegm accumulation and blood stasis. The treatment should not be limited to a single method but rather a combination of methods that boost and move qi, dissolve phlegm, and dispels stasis. Shēn Sū Yĭn was modified by removing qián hú, mù xiāng, shēng jiāng, and dà zăo, changing zĭ sū yè to zĭ sū gĕng, and zhĭ qiào to zhĭ shí in order to boost qi and dissolve stagnation. It was further tailored by adding guā lóu and shí chāng pú to loosen the chest and dissolve phlegm, dān shēn and chuān xiōng to dispel stasis and invigorate blood, and yù zhú to assist gāo lì shēn to replenish qi and fluids. As the formula corresponded exactly to the disease pattern, the result was very successful.

Má Huáng Xì Xīn Fù Zĭ Tāng 麻黄细⾟附⼦汤 Ephedra, Asarum and Aconite Decoction a.k.a. Má Xīn Fù Zĭ Tāng (麻⾟附⼦汤) Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Prepare it as a decoction. The decoction should be taken warm.

Formula Indications 1.This formula is indicated for patterns of yang-deficiency with externally contracted wind-cold. Signs and symptoms include fever, severe aversion to cold that does not improve even with thick layer of clothes and a quilt, lassitude, lethargy, and a deep and tiny pulse. 2.It is also indicated for a sudden loss of voice. Signs and symptoms include a sudden onset of a harsh voice, loss of voice, severe sore throat, aversion to cold, fever, lassitude, and lethargy. A pale tongue with a white coating and a deep and forceless pulse.

Analysis of Fundamental Pattern Pathogenesis 1 Su An. Application of Shēn Sū Yĭn in Senile Diseases 参苏饮在⽼年病中的运⽤. Shaanxi Journal of Traditional Chinese Medicine. 1991; (7): 315.

This formula is used for patterns of external wind-cold in a person with a yang-deficient constitution. Symptoms caused by exterior wind-cold pathogens struggling with zheng qi are fever and severe aversion to cold that are not resolved even when the patient is wearing a thick layer of clothes or a quilt. The deep and forceless pulse, lassitude, and lethargy are evidence of yang deficiency. Therefore, the treatment needs to simultaneously assist yang and release the exterior.

Formula Actions Assists yang to release the exterior.

Formula Analysis

Unique Combination Features Má Huáng Xì Xīn Fù Zĭ Tāng simultaneously treats the exterior and the interior by combining exterior-releasing and yang-boosting medicinals, and

the upper and the lower simultaneously by blending lung-diffusing and kidney-warming ingredients.

Further Clarification 1. About the combination of má huáng and fù zĭ Inducing sweat is the proper treatment method used for exterior patterns. However, in cases of yang deficiency, the body is not able to drive out the pathogens. There is also concern of leaking the already deficient yang when inducing sweat, which might possibly lead to yang collapse. Therefore, both yang-assisting and exterior-releasing methods must be applied in conjunction with each other in order to expel the pathogens without jeopardizing zheng, and enrich zheng without hindering the effort of expelling pathogens. In this formula, má huáng, with its exterior effect, opens the pores to expel the pathogens. Fù zĭ, which is more of an interior medicinal, rejuvenates yang qi so it can dispel the pathogens. With the two combined, they create mutual synergy. In addition, má huáng is a drastic sweat-inducing medicinal that may damage the yang qi in yang-deficient people. Fù zĭ, on the other hand, not only assists the yang to expel the pathogens, but it also prevents yang qi from leaking out. When má huáng and fù zĭ are combined, it eases the concern of yang collapse. Therefore, they make a common combination for assisting yang and releasing the exterior. 2. Why does the formula treat sudden loss of voice? The throat, with the shaoyin kidney channel passing along the base of the tongue, is the gate of the lung system. Therefore, a sudden loss of voice is due to extreme cold directly attacking the lung and kidney, blocking the upper orifices and kidney qi. Má huáng dissipates cold and diffuses lung qi, fù zĭ warms and enhances kidney yang, and xì xīn assists them both in order

to unblock the upper and lower conduits. The combination of the three diffuses the lung above, warms the kidney below, and opens up blocked orifices. It is a flexible formula exerting the spirit of “treating different diseases with the same method” by taking care of both the exterior and interior, or both the upper and lower systems.

Formula Applications 1. Essential pattern differentiation This is both a delegate and fundamental formula indicated for the pattern of shaoyin yang deficiency with externally contracted wind-cold. It is commonly used to treat sore throat and harsh voice caused by a pattern of extreme cold attacking and residing in the lung and the kidney. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a pattern of externally contracted pathogens in a yang-deficient constitution: common cold, flu, bronchitis, sick

sinus syndrome, rheumatic arthritis, allergic rhinitis, sudden blindness, sudden aphonia, laryngitis, and skin pruritus. 4. Cautions and contraindications If there is shaoyin yang deficiency with signs such as watery diarrhea containing indigested food, extremely cold limbs, and a feeble impalpable pulse, we must follow the principle of “warming the interior prior to fighting the exterior”[19] addressed by Zhang Zhong-jing. If the sweat-inducing method was to be mistakenly used in this situation, it would lead to yang collapse. Therefore, we have to take extra precaution.

Associated Formulas Má Huáng Fù Zĭ Gān Căo Tāng (Ephedra, Aconite and Licorice Decoction, 麻黄附⼦⽢草汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Má huáng should be decocted first and the foam that collects at the top of the decoction needs to be removed before adding the other medicinals. The decoction should be taken warm. [Actions] Assists yang to release the exterior. [Applicable Patterns]

Shaoyin yang deficiency and externally contracted wind-cold. Symptoms include: aversion to cold, body aches, low fever, facial edema, body edema, shortness of breath, difficult urination, and a deep and small pulse. Má Huáng Xì Xīn Fù Zĭ Tāng and Má Huáng Fù Zĭ Gān Căo Tāng are both indicated for patterns of externally contracted wind-cold in yangdeficient patients. However, the condition of which the former is indicated for is urgent and severe, marked by serious exterior and interior cold. Má huáng and fù zĭ are combined with xì xīn to assist yang and induce sweating that provides fast relief from the exterior and interior pathogens. The latter is appropriate for a less urgent and less severe disease condition. Má huáng and fù zĭ are combined with gān căo to assist yang to induce a light sweat in order to remove exterior and interior pathogens in a moderate manner. The disease condition may be either moderate or severe, and the treatment either slow-paced or urgent.

Case Studies 1. Headache Deng, an adult male, was initially ill with an externally contracted cold and mistakenly took an acrid-cool formula with no effect. Some ten days later, he developed an unbearable chopping headache. In the afternoons, he had aversion to cold, body aches, a deep, weak and forceless pulse, and a white and glossy tongue coating with no desire for water. The pattern was cold sticking in shaoyin and blocked clear yang from rising. The acrid-cool formula further consumed genuine yang which led to yin-cold blocking the channels and vessels. The head, the converging place of the yang channels, was therefore invaded by pathogenic yin preventing the yang from circulating. The struggle between the pathogen and zheng qi led to his

current condition. Má Huáng Xì Xīn Fù Zĭ Tāng with additions was prescribed according to the method of assisting the zheng to remove pathogens. The ingredients included fù zĭ 100 g, gān jiāng 36 g, gān căo 6 g, má huáng 10 g, xì xīn 5 g, and qiāng huó 10 g. He took one dose and the headache and pain were significantly alleviated. A second dose took care of the rest.1 Comments: The headache was due to a pattern of shaoyin yangdeficiency with externally contracted wind-cold, showing aversion to cold, body aches, a deep, weak and forceless pulse, and a white and glossy coating. By blending Má Huáng Xì Xīn Fù Zĭ Tāng and Sì Nì Tāng together, the formula became a good example in treating concurrent taiyin and shaoyin disease with the action of warming the channels. 2. Pharyngalgia 1 Wu Pei-heng. Wu Pei-heng’s Case Records 吴佩衡医案. Kunming: Yunnan People’s Publishing House; 1979. p. 47.

A 39-year-old male agriculture worker presented with a chronic sore throat that had lasted for more than a year. All of the hospitals he had visited diagnosed the illness as chronic pharyngitis and prescribed medications including penicillin, streptomycin, and terramycin. He showed the author a list of all the previous Chinese medical formulas he was prescribed. They were all heat-clearing, firedraining, yin-nourishing, and sore throat-relieving formulas. He was carefully questioned and his signs and symptoms were aversion to cold, recurring headache, toothache, body aches that moved around, body itchiness, muffled cough, thirst with a lack of desire for water, favored hot water, fatigue, and lethargy. Defecation and urination were normal. His tongue coating was thin, white and quite moist, and his pulse was slow. The pattern was externally contracted cold invading the yangdeficient shaoyin. Therefore, the treatment should warm the channel,

dissipate cold, assist yang, and release the exterior. He was prescribed three doses of Má Huáng Fù Zĭ Xì Xīn Tāng composed of má huáng 5 g, fù zĭ 10 g, and xì xīn 3 g. After completing the doses his toothache disappeared and the aversion to cold, headache, and body aches were alleviated. His sore throat changed from being persistent to sporadic. On his second visit, he had a distended abdomen and left hypochondriac pain that radiated to the left back. Three doses of a second prescription based on the previous formula was prescribed with the addition of xiāng fù, sū gĕng, and xìng rén, 10 g each. His toothache, headache, sore throat, and lethargy were all eliminated with improved vitality, reduced abdominal distention, and cessation of the itching. He continued taking the formula with modifications for another twelve doses, and recovered completely without noted recurrence.1 Comments: The throat connects to the lung, with all three foot yin channels passing through it. In this case, the patient had a deficient yang constitution and his foot taiyin and foot shaoyin were attacked by cold pathogen that blocked the lung qi. The lung failed to diffuse and descend which further led to difficult qi transformation. His sore throat occurred due to an accumulation and blockage of qi, blood, and fluids in the area of the throat. The formula used má huáng to dissipate exterior windcold and diffuse blocked lung qi. It used fù zĭ to warm the kidney yang and assist qi transformation and boost the heart yang to smooth blood flow. It used xì xīn to unblock the shaoyin channel, and assist má huáng and fù zĭ to unclog the upper and lower body. Thereby, the lung qi could diffuse allowing for the free flow of blood and fluids, the stagnation around throat was resolved, and the sore throat cured. If the case had not been carefully analyzed, the mind would be obsessed by the word “inflammation”. How could the treatment be effective when bitter-cold medicinals were used again and again?

Zài Zào Săn 再造散Renewal Powder Source Text Six Texts on Cold Damage (Shāng Hán Liù Shū, 伤寒六书)

Formula Ingredients

Preparation and Administration Add two pieces of dà zăo and prepare it as a decoction. Take it while it is warm. 1 Li Xing-pei. Treating Pharyngalgia of Shaoyin Pattern with Má Huáng Xì Xīn Fù Zĭ Tāng 麻黄 附⼦细⾟汤治少阴咽痛. Jiangsu Journal of Traditional Chinese Medicine. 1988; (6): 27.

Formula Indications

This formula is indicated for deficient and weak yang qi with externally contracted wind-cold. The symptoms are aversion to cold, chills more than fever, no perspiration, cold limbs, fatigue, lassitude, sleepiness, a pallor face, and a low voice. The tongue is pale with a white coating, and the pulse is deep and forceless or superficial, large and forceless.

Analysis of Fundamental Pattern Pathogenesis Aversion to cold, fever, and absence of sweat are clear evidence of externally contracted windcold with pathogens at the surface of the flesh. Relatively mild fever with more serious chills, cold limbs, sleepiness, fatigue, dislike to speak, and a pallor face are signs of yang qi deficient body with externally contracted wind-cold. Wei yang roots from kidney yang, so that it must be insufficient when kidney yang is deficient. Since the four limbs cannot be warmed by yang qi, they are cold and the patient prefers to lie down. The generation and transformation of qi, blood, fluids and essence are dependent upon yang qi while the zang-fu organs need yang qi for energy. When yang qi is waned, zang-fu organs are weak, and qi and blood are inadequate, showing symptoms such as lassitude, dislike to speak, a pallor face, and a deep, thready, and forceless pulse. The suitable treatment method is to release the exterior, dissipate cold, assist yang, and boost qi simultaneously.

Formula Actions Releases the exterior, dissipates cold, assists yang, and boosts qi.

Formula Analysis

Unique Combination Features First, this formula concurrently uses medicinals that release the exterior with those that boost qi and assist yang. Thereby, it supplements zheng qi while it induces sweating to address the root cause and the branch simultaneously. Second, it utilizes dispersing medicinals and astringing medicinals; so it restrains while dispersing, without jeopardizing the zheng qi.

Formula Applications 1. Essential pattern differentiation

This is a common formula used to boost qi and assist yang in order to release the exterior. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in biomedically defined disorders such as senile common cold and rheumatic arthritis showing signs of yang qi deficiency with an externally contracted wind-cold pattern.

Comparison & Contrast Má Huáng Xì Xīn Fù Zĭ Tāng vs. Zài Zào Săn

Continued

Case Studies 1. Externally contracted cold without sweating Wu, a 36-year-old female agricultural worker visited the clinic on March 22nd, 2005. Her signs and symptoms included aversion to cold, absence of sweat, sore and tight head and body for fortyfive days, severe chills more than fever, cold limbs that improved with heat, lassitude, fatigue, favored warmth and lying down, a pale tongue with a white coating, and a deep and slow pulse. She took different kinds of Western and Chinese

medicine that would alleviate the symptoms but would then reoccur after one to two days. The more frequent she used them, the less effective they were. This was especially true for antipyretic and analgesic agents. She was easy to catch cold, difficult to recover, and hard to sweat. Her pattern was differentiated as insufficient yang with externally contracted cold blocking the striae and interstices. The treatment method selected was to assist yang, boost qi, induce sweat, and vent exterior pathogens. Two doses of modified Zài Zào Săn were prescribed composed of huáng qí 6 g, rén shēn 3 g, shú fù zĭ (boil down first) 3 g, guì zhī 3 g, wēi jiāng 3 g, fáng fēng 3 g, jīng jiè 3 g, qiāng huó 3 g, chuān xiōng 3 g, chăo bái sháo 3 g, dà zăo 3 g, gān căo 2 g, and xì xīn 2 g. The formula was prepared as a decoction and taken warm. Sweating was induced and her symptoms were alleviated. She completely recovered with additional two doses of the same formula to consolidate the treatment efficacy. A six-month follow-up did not show recurrence.1 2. Externally contracted cold with sweating 1 Lu Guo. Clinical Experience with Zài Zào Săn 再造散临床应⽤的体会. Guangming Journal of Chinese Medicine. 2008; (4): 501.

Tang, a 48-year-old female teacher visited the clinic on November 20th, 2001. She had spontaneous sweating and aversion to wind for thirty days. Other signs and symptoms included headache, mild fever, labored breathing during physical activities, cold sweat, post-sweating aversion to wind-cold, chills, cold limbs, a pale face, lassitude, dislike to talk, favored of thick layers of clothes and quilts, a pale tongue with a white coating, and a superficial, large and forceless pulse. She got cold easily, was slow to recover, and was overweight. Her disease pattern was insufficient yang with externally contracted cold, the pores were open with loose flesh, and relatively stronger wei and weaker ying. The treatment was to assist yang, boost qi, vent exterior pathogens, release the flesh, and harmonize ying and

wei. She was prescribed a modified Zài Zào Săn composed of huáng qí 6 g, rén shēn 3 g, shú fù zĭ (boil down first) 3 g, wēi jiāng 3 g, guì zhī 3 g, fáng fēng 3 g, bái zhú 3 g, cōng bái 3 g, and gān căo 3 g. She was advised to avoid being chilled by wind-cold. Her condition was alleviated by the second visit, so her prescription was changed by adding shān zhū yú 6 g and shān yào 10 g for three dosages. She completely recovered this time. She continued with a subsequent prescription composed of fáng fēng 30 g, huáng qí 30 g and bái zhú 60 g ground to powder. She was instructed to swallow the powder with boiled water, 6 g each time twice daily. A five-month followup did not show recurrence.1 Comments: Although both cases applied modified Zài Zào Săn, the difference of the disease condition was sweating versus no sweating. The first case had absence of sweat, aversion to cold, and cold limbs that would improve with heat. The patient was lacking vitality, fatigued, favored warmth and lying down, had a pale tongue with a white coating, and a deep and slow pulse in a pattern of “exterior excess” with existing yangdeficiency and qi-weakness. The use of Zài Zào Săn with added jīng jiè was able to induce sweating and resolve the disease. The second case, however, presented with sweating and aversion to wind, chills, cold limbs, a pale face, lassitude, dislike of talking, favoring thick layers of clothes and quilts, a pale tongue with a white coating, and a superficial, large, and forceless pulse. It was a pattern of deficient exterior deficiency in a constitution of yang-deficiency and qi-weakness. With the wei relatively stronger than the weaker ying, the exterior flesh was loose. Therefore cōng bái, a milder medicinal, was used to substitute strong acridscattering qiāng huó and xì xīn and teamed with bái zhú and fú xiăo mài to prevent the damage of yang led by excessive sweat promotion. Upon the second visit, shān zhū yú and shān yào were added to supplement the kidney

and the spleen to boost the source in transforming and generating wei qi. The third visit applied Yù Píng Fēng Săn to boost qi, enhance wei, and consolidate the efficacy. Zài Zào Săn is structured by removing má huáng from Má Huáng Fù Zĭ Xì Xīn Tāng, combining with Guì Zhī Tāng for its ying-wei regulating action, and adding medicinals such as rén shēn, huáng qí, qiāng huó, fáng fēng, and chuān xiōng. The addition of jīng jiè in this case was to enhance the sweat-inducing effect for the excess exterior pattern in order to recover yang and promote sweating to cure the disease. The intentional removal of qiāng huó and xì xīn decreased the acrid-scattering action and focused it to assist yang, boost qi, release the exterior, vent exterior pathogen, and regulate ying and wei. The result was the recovery of yang, harmony of ying and wei, and alleviation of the disease condition. With that said, Zài Zào Săn is quite effective for patterns with or without sweating. 3. Bí qiú (allergic rhinitis, ⿐鼽) 1 Lu Guo. Clinical Experience with Zài Zào Săn 再造散临床应⽤的体会. Guangming Journal of Chinese Medicine. 2008; (4): 501.

A 24-year-old male patient visited the clinic on September 16th, 1976. During the summer of 1972, the patient often used lukewarm or cold water to bath after laborious work with the thought that he was young and strong. Then, he developed cold-like symptoms such as bí qiú (allergic rhinitis), but ignored it. By 1974, it was hard for him to avoid the above symptoms from happening, even though he took health maintenance measures carefully during fall, winter, and spring. In the worst scenarios, when he took off his clothes to sleep or gargle with cold water the symptoms, including sneezing, nose itchiness, runny nose with clear discharge, dizziness, headache, tinnitus and fatigue, would appear. His condition persisted for two years. On August 27th, 1976, after long distance travel, he was tired and contracted wind while

sweating which triggered the onset of bí qiú with the above symptoms. He took terramycin and chlortrimeton for ten days without improvement, so he then turned to the author. Upon examination he was found to have a pale face with little luster, lacking vitality, a pale tongue with a thin white coating, and a moderate, weak pulse. By correlating the pulse and symptoms, the diagnosis was deficiency of lung qi and unsecured exterior wei qi. Thereby, the treatment was to boost qi, assist yang, release the exterior, and dissipate wind-cold. He was prescribed modified Zài Zào Săn containing dǎng shēn 15 g, huáng qí 15 g, fù piàn 5 g, guì zhī 5 g, gān cǎo 5 g, xì xīn 3 g, qiāng huó 10 g, fáng fēng 10 g, chuān xiōng 10 g, bái sháo 10 g, shān yú ròu 10 g, bŭ gŭ zhī 10 g, and wǔ wèi zǐ 10 g. The patient took thirty doses continuously and his condition was completely relieved. There has been no recurrence of the condition. 1 Comments: The main symptoms of bí qiú are clear nasal discharge, stuffy nose, and sneezing; similar to biomedically defined allergic rhinitis. When the patient in this case was not taking healthretaining measures, he would abruptly sneeze, his nose would itch, and it would run. These are signs of unsecured wei qi, easy to contract external pathogen. He had the condition for four years with signs and symptoms of deficient yang qi, including a pale face, very little luster, lack of vitality, a pale tongue with a thin white coating, and a moderate, weak pulse. The occurrence that prompted his visit was due to fatigue following long-distance travel and contracting wind while sweating. In short, the disease mechanism for the pattern in this case was yang qi weakness and unsecured exterior wei leading to external contraction of wind-cold and blockage of the lung qi. Zài Zào Săn was prescribed to boost qi, assist yang, release the exterior, and dissipate wind-cold with added medicinals such as shān zhū yú and pò gù zhĭ used to

enhance the action of warming the kidney yang in order to secure the exterior.

Jiā Jiăn Wēi Ruí Tāng 加减葳蕤汤Solomon’s Seal Variant Decoction Source Text Popular Guide to ‘Treatise on Cold Damage’ (Tōng Sú Shāng Hán Lùn, 通俗伤寒论)

Formula Ingredients

1 Chen Nai-gong. Treatment Summary on 30 Cases of Bummar with Zài Zào Săn 再造散治疗⿐ 鼽30例临床⼩结. Shanxi Journal of Traditional Chinese Medicine. 1994; 10 (2): 13.

Preparation and Administration Prepare it as a decoction. It should be taken warm.

Formula Indications Jiā Jiăn Wēi Ruí Tāng is indicated for the pattern of yin deficient with external contraction of wind-heat. The signs and symptoms are headache,

fever, slight aversion to wind-cold, absence of or a little bit of sweat, cough, vexation, thirst, dry throat, a red tongue, and a rapid pulse.

Analysis of Fundamental Pattern Pathogenesis The formula is indicated for patients who are yin-deficient and have contracted external wind-heat. Exterior wind-heat causes symptoms such as headache, fever, slight aversion to wind-cold, absence of or inhibited sweat, cough, and thirst. When people with a yin-deficient constitution contract an external pathogen, it tends to transform into heat. At the same time, yindeficient people usually have internal heat. Hence, they may also have symptoms such as dry throat, vexation, a red tongue, and a rapid pulse and the manifestation of pathogens attacking the lung wei. Consequently, the appropriate treatment will be to release the exterior with acrid-cool medicinals, nourish yin, and clear heat.

Formula Actions Nourishes yin and releases the exterior.

Formula Analysis

Unique Combination Features The combination of exterior-releasing and yin-nourishing medicinals is effective to induce sweating without damaging yin, and nourish without retaining the pathogen.

Further Clarification The combination of bò he and yù zhú can satisfy both the requirements of nourishing yin and releasing the exterior. When a yin-deficient patient has contracted an external pathogen, he does not have the fluids needed for sweating. Consequently, if we only induce sweating to release the exterior, the pathogen will not be released and there is the risk of yin-fluid damage. In this formula, the sweetcold yù zhú is the major medicinal used to nourish yin

and moisten dryness. It enters the lung and the stomach channels to moisten the lung, nourish the stomach, clear heat, and promote fluids. Moreover, most yin-nourishing medicinals are rich and cloying, yù zhú is an exception, so it fits the condition of yin-deficiency with exterior heat especially well. At the same time, acrid-cool bò he is an important medicinal for patients suffering from warm disease who need to release the exterior by scattering wind-heat. Thus, the combination makes a fundamental structure of nourishing yin and releasing the exterior.

Formula Applications 1. Essential pattern differentiation Jiā Jiăn Wēi Ruí Tāng is especially designated for yin-deficient people who have contracted external wind-heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications The formula is commonly used for elderly and post-partum patients affected by common cold, acute tonsillitis, and pharyngitis that have a yindeficiency pattern complicated by external contraction.

4. Cautions and contraindications This formula is appropriate for nourishing yin and releasing the exterior. Therefore, if the disease pattern is not yin deficiency, it is not suitable for the condition. Otherwise, the exterior pathogen will linger and be difficult to remove.

Associated Formulas Cōng Bái Qī Wèi Yĭn (Scallion Seven Ingredients Beverage, 葱⽩七味 饮) [Source] Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘 要) [Ingredients]

[Preparation and Administration] Use water (scoop-poured 1000 times) 8 sheng to decoct the medicinals until 1/3 water were remained. The decoction should be taken warm. [Actions] Nourishes blood, and releases the exterior. [Applicable Patterns] Deficient yin-blood after an illness without good care and an externally contracted pathogen; external wind-cold contraction after losing blood

(hematemesis, occult blood, hemoptysis or epistaxis), having headache, body heat, slight aversion to cold and no sweat. Both Cōng Bái Qī Wèi Yĭn and Jiā Jiăn Wēi Ruí Tāng combine medicinals that enrich yin and nourish blood with those that release the exterior. Cōng Bái Qī Wèi Yĭn, using blood-nourishing and acrid-warm exterior-releasing medicinals, is a representative formula for treating the pattern of blood-deficiency complicated by exterior wind-cold marked by headache, body heat, aversion to cold, and no sweating with evidence of blood deficiency or a history of hemorrhage. Whereas Jiā Jiăn Wēi Ruí Tāng, combines medicinals that enrich yin and release the exterior with acrid-cold creating a principle formula used to treat the pattern of yindeficiency complicated by exterior windheat. The clinical signs and symptoms include body heat, slight aversion to cold, sweating or light sweating, thirst, vexation, a dry throat, a red tongue, and a rapid pulse.

Case Studies Common cold Yin, a 54-year-old factory worker had a chronic condition of lung consumption (láo zhài, 痨瘵) and strangury with symptoms of vexing heat in the five centers and dry throat in the night. Last night, she had additional symptoms of chills, aversion to wind, no sweating, dizziness, tearing, distention of the eyes, yellow and very warm urine, a superficial thin and rapid pulse, and a red tongue without coating. Her body temperature was 38.9°C (102°F). Considering her yin deficient condition and the newly symptoms exterior wind, two doses of modified Jiā Jiăn Wēi Ruí Tāng were prescribed containing yù zhú 24 g, bái wēi 24 g, mài dōng 15 g, dòu chĭ 9 g, bò he 4.5 g, gān căo 6 g, dà zăo 4 pieces, qīng hāo 12 g, pái fēng téng 24 g, sāng yè 9 g, and jú huā 9 g. Her body temperature decreased as the

symptoms of the exterior pattern disappeared. Since she still felt thirst, tastelessness, lassitude, and insufficient qi, modified Zhú Yè Shí Gāo Tāng was prescribed to boost qi, nourish yin, and clear residual heat.1 Comments: Chronic diseases such as lung consumption and strangury have continuous damage to yin blood with specific manifestations of vexing heat in the chest, palms and soles, and dry throat in the middle of the night. Therefore, the patient had a yin deficient constitution. Upon her visit, she had new signs and symptoms of an exterior pattern including aversion to wind-cold, body heat, absence of sweat, dry and bitter mouth, yellow and very warm urine, and a superficial pulse. It was diagnosed as a pattern of yin deficiency with external contraction, a condition involving both the exterior and interior, for which releasing the exterior was the priority. Therefore, a modified Jiā Jiăn Wēi Ruí Tāng was prescribed to primarily releasing the exterior with the secondary consideration of nourishing yin with the addition of qīng hāo, pái fēng téng, sāng yè and jú huā to enhance the wind-scattering and heat-clearing effect, and mài dōng was used to protect yin due to her chronic condition. 1 Lian Jian-wei, Li Ji. The Case Study Version of Chinese Medicinal Formulas ⽅剂学案例版. Beijing: Sciences Press; 2006. p. 25.

Endnotes: [1] 其有邪者，渍形以为汗，其在⽪者，汗⽽发之 [2] 善治者，治⽪⽑，其次治肌肤，其次治筋脉，其次治六腑，其 次治五脏，治五脏者，半死半⽣也 [3] 太阳中风 [4] 营弱卫强 [5] 为仲景群⽅之冠，乃滋阴和阳，调和营卫，解肌发汗之总⽅也 [6] 发汗后，遂漏不⽌，其⼈恶风 [7] 以上九味，虽为⼀⽅，然亦不可执 [8] 当视经络前后左右之不同，从其多少、⼤⼩、轻重之不⼀，增 损⽤之 [9] 其效如神 [10] 以轻松流利为佳，不必动辄峻剂也 [11] 温邪上受，⾸先犯肺 [12] ⾹⽓⼤出，即取服，勿过煮 [13] 过煮则味厚⽽入中焦矣 [14] 汗出⽽喘 [15] 无汗⽽喘 [16] 逆流挽⾈ [17] ⾏⾎则便脓⾃愈，调⽓则后重⾃除

[18] 痈疽原是⽕毒⽣ [19] 先温其⾥，乃攻其表

Summary Exterior-releasing formulas are mainly applied for exterior patterns caused by external contraction of the six pathogenic factors. This chapter described eighteen fundamental and twenty-one associated formulas. According to their actions, they were classified into three exterior-releasing categories:

● Acrid-warm exterior-releasing formulas ● Acrid-cool exterior-releasing formulas ● Zheng-enhancing exterior-releasing formulas 1. Acrid-warm exterior-releasing formulas These formulas are appropriate for patterns of externally contracted wind-cold. Among them, Má Huáng Tāng has a powerful function to not only promote sweat and scatter cold, but also diffuse the lung and calm labored breathing by combining má huáng with guì zhī. It is a strong acridwarm exterior-releasing formula suitable for excess patterns of externally contracted wind-cold with symptoms of aversion to cold, fever, absence of sweat, and labored breathing. Guì Zhī Tāng employs both guì zhī and bái sháo with a weaker function to promote sweat and release the exterior. However, it is great for regulating ying and wei, which makes it a harmonizing formula used to release the exterior with acrid-warmth. It can be used in deficient pattern of externally contracted wind-cold marked by fever and aversion to wind, as well as, miscellaneous diseases with disharmony of ying and wei.

Jiŭ Wèi Qiāng Huó Tāng has a strong effect to simultaneously induce sweat, dispel dampness, and clear internal heat. It is proper for externally contracted wind-cold complicated by dampness with fever, absence of sweat, body aches, and internal heat symptoms such as a bitter mouth and thirst. Xiāng Sū Săn has the function to scatter and dissipate external windcold, rectify qi and harmonize the middle jiao. It is appropriate for an externally contracted wind-cold with qi constraint pattern, marked by aversion to cold, general fever, headache, absence of sweating, chest and epigastric fullness and distress, and lack of appetite. Xiăo Qīng Lóng Tāng is good at releasing the exterior, warming the lung, and dissolving rheum. It is perfect for people with chronic, enduring internal cold complicated by externally contracted wind-cold with symptoms of aversion to cold, fever, cough, labored breathing, large amounts of clear thin phlegm, and fullness in the chest and diaphragm. Zhĭ Sòu Săn is capable of diffusing the lung qi and scattering wind to relieve cough with warm, moist, harmonizing, and gentle ingredients. It is suitable for the pattern of externally contracted wind not completely resolved and disordered lung qi following the release of the exterior. It can be applied to all kinds of coughs with appropriate modifications. Zhèng Chái Hú Yĭn is an exterior-releasing formula created by Zhang Jie-bin with gentle, balanced medicinal effects. It is appropriate for externally contracted wind-cold without qi and blood deficiency. 2. Acrid-cool exterior-releasing formulas This category of formulas is appropriate for patterns of externally contracted wind-heat or early stages of windwarmth. Yín Qiào Săn and Sāng Jú Yĭn are commonly used formulas for treating patterns of exterior wind-heat. Yín Qiào Săn, a gentle acrid-cool formula, has the stronger effect

to release the exterior with its ability to clear heat and resolve toxins. It is suitable for wind-heat attacking the lung wei, with a high fever, mild chills, cough, and sore throat. Sāng Jú Yĭn is a comparatively light, acrid-cool formula. Its major effect is to diffuse the lung and stop cough, which makes it appropriate for light wind-heat residing in the lung collaterals marked by coughing. Má Huáng Xìng Rén Gān Căo Shí Gāo Tāng is a strong acridcool formula used to diffuse the lung, clear heat, and calm labored breathing. It is appropriate for the pattern of lung heat with cough and labored breathing due to external pathogens that have penetrated the interior and transforming into heat. When it is applied, the quantity of má huáng and shí gāo needs to be adjusted according to the degree of fever, and whether there is sweating. Chái Gé Jiĕ Jī Tāng is used to release the flesh and clear heat. It is perfect for the pattern of early stage wind-cold attacking yangming and transforming into internal heat, or combined three-yang disease. It is marked by gradually reduced aversion to cold with increased body heat, no sweating, headache, dry nose and throat, orbital pain, and a superficial, surging pulse. Fáng Fēng Tōng Shèng Săn scatters and dissipates wind-heat to vent exterior pathogens and drains heat by purgation to remove interior excess. It is appropriate for accumulated wind-heat with excess in both the exterior and interior. Signs and symptoms include aversion to cold, high fever, bitter mouth, dry throat, constipation, inhibited urination, a yellow coating, and a rapid pulse. Shēng Má Gé Gēn Tāng, the last formula in this section, is appropriate for patients who have measles that have not erupted along with fever and an absence of sweat. 3. Zheng-enhancing exterior-releasing formulas

These formulas address zheng qi deficiency complicated by externally contracted pathogens. Bài Dú Săn and Shēn Sū Yĭn are both qi-boosting, exterior-releasing formulas. However, Bài Dú Săn has stronger coldscattering and dampness-dissolving effect appropriate for more serious patterns of externally contracted wind-cold-dampness. The latter is better to boost qi, regulate the lung, and dissolve phlegm. It is appropriate for qi deficiency with externally contracted wind-cold complicated by phlegm blocking qi. Má Huáng Xì Xīn Fù Zĭ Tāng and Zài Zào Săn both are formulas used to support yang and release the exterior. Má Huáng Xì Xīn Fù Zĭ Tāng combines acrid-warm, sweatinducing medicinals with internalwarming and yang-enhancing medicinals. It is great for yang deficiency with externally contracted wind-cold. Zài Zào Săn, on the other hand, is a modified combination of Guì Zhī Tāng and Má Huáng Xì Xīn Fù Zĭ Tāng structured by removing má huáng and adding qiāng huó, fáng fēng, rén shēn, and huáng qí. It is suitable for yang deficiency and qi weakness in those who are affected by external wind-cold. Last but not least, Jiā Jiăn Wēi Ruí Tāng, with actions of nourishing yin and releasing the exterior, is proper for people who are yin deficient and have contracted external windheat.

Questions 1.Who created Jiŭ Wèi Qiāng Huó Tāng? What unique combination features does this formula embody? 2.Why do we say that the combinations found in Zhĭ Sòu Săn reflect the characteristics of warmth, moistening, harmonizing, and gentleness? 3.Why can Má Xìng Shí Gān Tāng be applied whether or not there is sweating?

4.Why do we need to simultaneously release the exterior and boost qi when treating patterns of qi-deficiency with external contraction?

CHAPTER 2 DownwardDraining Formulas Downward-draining formulas utilize downward-draining medicinals as their key components. They have the therapeutic actions to unblock the bowels and to remove accumulations and expel water through purgation. Downward-draining formulas are prescribed to treat interior excess patterns. The modern “downward-draining” method was historically referred to as the “purgation method”. It is one of the eight treatment methods recorded in ancient literature. Generally speaking, interior excess pattern refers to those patterns that are located in the interior with an excess nature. The formulas that drain downward are suitable for interior excess patterns caused by retained food, dried stool, retained fluid, and static blood, visible pathogens, which have accumulated in the interior. This pattern is mainly characterized by constipation, stuffiness and fullness, or distention and pain in the epigastrium and abdomen. As these visible pathogens accumulate in the interior, they develop into an excess pattern. For this reason, the therapeutic principle “pathogens in the lower requiring dredging, abdominal fullness is treated by elimination”[1] described in The Yellow Emperor’s Inner Classic: Basic Questions (Huáng Dì Nèi Jīng—Sù Wèn,黄帝内经·素问) should be used. Downward-draining formulas remove the visible pathogenic influences by draining them through the stool.

Interior excess accumulation patterns vary as heat accumulations, cold accumulations, dryness accumulations, and fluid accumulations. They also vary between insufficient and excess constitutions. Therefore, interior excess patterns are divided into a variety of patterns with corresponding treatment methods, formulas, and ingredients. Formulas that drain downward are classified into five types: formulas that are cold and purge are used to treat accumulations due to heat excess in the interior, formulas that are warm and purge are used to treat accumulations due to cold excess in the interior, formulas that moisten and purge are used to treat constipation due to dryness in the intestines, formulas that drive out excess water are used to treat accumulations of water and fluids that obstruct in the interior, and formulas that attack and supplement are used to treat excess in the interior with deficient right qi. Downward-draining formulas are designed for interior excess patterns. Four points described below should be emphasized while using the formulas. First, we cannot use the formulas until any exterior patterns are resolved and an interior excess pattern has appeared. If an exterior pattern cannot be resolved and an interior excess pattern has developed, it is important to consider which is more severe and urgent between the exterior and internal excess patterns. The priority is to relieve any exterior patterns or, if need be, to address both simultaneously rather than adopting the downward-draining method alone. This is done to prevent an exterior pathogen accidently becoming lodged in the interior and then develop into other patterns. Second, all of these formulas that drain downward, except for the formulas that moisten and purge, contain harsh ingredients that must be prescribed with care. Even when constipation is pronounced, they are contraindicated during pregnancy, after childbirth, and during the menstrual period. They are also contraindicated for the elderly, weak patients, those with depleted fluids,

or who have had a loss of blood due to other disorders. It is necessary to add tonic medicinals and avoid purgation for fear of damaging the zheng qi. Third, the harshness of these formulas can easily injure the stomach qi, so their use should be discontinued as soon as they take effect. Fourth, foods that are greasy or difficult to digest increase the risk of injuring the stomach qi and therefore should be avoided when taking these formulas.

Section 1 Cold Purgative Formulas Cold purgative formulas are used to treat patterns of interior excess heat accumulations. The signs and symptoms include distention, fullness and pain in the abdomen, possible tidal fever, a thick yellow tongue coating, and an excess pulse. The formulas commonly consist of ingredients with cold properties, such as dà huáng and máng xiāo. Excess heat accumulates in the intestines and stomach and often leads to qi stagnation or even blood stasis caused by qi stagnation. Therefore, it is common to add medicinals that move qi such as zhĭ shí and hòu pò, as well as medicinals that invigorate blood and dispel stasis such as táo rén and dān pí to the formula being used. Representative formulas are Dà Chéng Qì Tāng, Dà Huáng Mŭ Dān Tāng, and Dà Xiàn Xiōng Tāng.

Dà Chéng Qì Tāng ⼤承⽓汤Major Purgative Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Dà Chéng Qì Tāng is prepared as a decoction. Hòu pò and zhĭ shí should be decocted first, then dà huáng added later while it is cooking, and finally dissolve the máng xiāo into the strained decoction. The decoction should be taken warm in two divided doses for oral administration. Once loose stool appears, the decoction should be discontinued.

Formula Indications 1.Excess heat in the yangming fu-organs. The symptoms are constipation with frequent flatulence, gastric stuffiness and abdominal fullness, abdominal pain that feels worse with pressure, and the abdomen is tense and firm when pressed. In severe cases, there may be tidal fever, delirious speech, and profuse sweating from the palms and soles. The tongue coating is dry and yellow with prickles, or dry and parched black with cracks. The pulse is deep and excessive. 2.Heat retention with watery discharge. The symptoms are watery green, foul-smelling diarrhea, umbilical and abdominal pain, hardness with clumps felt when pressing the abdomen, and a dry mouth and tongue. The pulse is slippery and excessive. 3.Internal excess heat. The symptoms are heat inversion, convulsive disease, and mania.

Analysis of Fundamental Pattern Pathogenesis The pathogenesis of this pattern is exuberant yangming heat that consumes fluids and dries the stool. Pathogenic heat binds with dry stool to form an excess pattern, which obstructs the qi of the fu-organ. Therefore, the characteristics of this pathomechanism may be simplified as “stuffiness, fullness, dryness, and excess”[2]. Stuffiness refers to the sensation of oppression, obstruction, and heaviness focused in the chest and epigastrium. Fullness refers to distention and fullness of the epigastrium and abdomen that is resistant to palpation. Dryness refers to dry bound stool that accumulates in the intestines causing difficult defecation. Excess refers to the accumulation of heat that has taken form, abdominal pain that is resistant to pressure, constipation, tidal fever, delirious speech, and an excess pulse. When there is watery diarrhea, neither the abdominal fullness nor pain is relieved. When qi stagnation constrains the distribution of yang qi throughout the four limbs, it leads to a pattern called heat inversion. Exuberant heat damages and dries the fluids which causes spasms of tendons and vessels because of the loss of nourishment, which is referred to as convulsive disease. Pathogenic yangming heat rises to disturb the spirit of heart, located above the yangming domain, causing mania. Although all of these manifestations are different, they have the same pathomechanism of severe heat accumulation. It should be treated by drastically purging the heat accumulation in order to prevent the depletion of fluids. This treatment method is described as extracting the firewood from under the cauldron.

Formula Actions Drastically purges heat accumulation.

Formula Analysis

Unique Combination Features First, dà huáng and máng xiāo are used in mutual promotion to increase the purging action. Second, there is equal emphasis on purging and moving qi; purging will benefit the flow of qi in the stomach and intestine, while moving qi will facilitate the purging. Hence, the Treatise on Cold Damage described this formula as “a drastically purging formula”[3].

Further Clarification 1.Dà Chéng Qì Tāng treats heat retention with watery discharge. If there is watery discharge, why is the purgative method still used? An indication of this formula, watery discharge, is caused by dry, hard stool, which fails to be expelled by the stomach and intestines and is retained in the interior. Thereby intestinal fluid moves down the intestinal tract and

forced around the dry stool in the intestines. Even after the patient excretes turbid foul-smelling watery discharge, they will still have hard knots in the abdomen that render it painful around the umbilicus. Actually the watery discharge is an indirect “false” sign whereas the hard and dry stool is the real cause. Therefore, Dà Chéng Qì Tāng is used to “treat the flowing by promoting its flow”[4] by expelling dry stool in the stomach and intestines through purgation so the diarrhea can be stopped. 2.What is the mechanism of this formula that treats heat syncope? The reversal counter-flow cold of the limbs is a false symptom while internal excess of heat bind is the true pathology; akin to the concept “the more severe the heat is, the more severe the syncope is”. Though the patient has cold limbs, he must also have signs of internal excess and heat bind, such as constipation, abdominal pain aggravated by pressure, dry mouth with thirst, and a slippery, excess pulse. This formula clears heat bind through drastic purgation, which then allows the qi movement to normalize and the limbs to warm by the arrival of yang qi. This method is also called “treating cold with cold”[5] because it treats cold limbs with cold purgation. 3.Why is it that this formula does not have to be combined with medicinals that cool the liver, extinguish wind, nourish yin, and relax the tendons in order to treat convulsions? The convulsion treated by this formula is caused by exuberant heat in the stomach and intestines drying up the body fluids. The tendons then convulse because of the lack of nourishment. The patient must have signs of excess heat, such as constipation, dry mouth, and a slippery, rapid pulse. This formula saves yin through drastic purgation, so the fluids can be recovered in order to nourish the tendons. Once the heat is gone, the convulsion is stopped. This is the method of treating the root.

4.Why should dà huáng be raw and added into the decoction towards the end of the cook regime? Dà Chéng Qì Tāng was formulated to drastically purge. The purgative power of raw dà huáng is stronger especially when it is cooked for a short time. Prepared dà huáng has a gentler purgative action, more so when decocted longer.

Formula Applications 1. Essential pattern differentiation Dà Chéng Qì Tāng is the basic formula used to treat yangming bowel excess and the representative formula of cold purgation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a yangming bowel excess pattern: acute simple intestinal obstruction, adhesive intestinal obstruction, ascaris intestinal obstruction, acute cholecystitis, acute pancreatitis, and incomplete pyloric obstruction; or when the patient shows signs of constipation, a

yellow tongue coating, and an excess pulse: hyperpyrexia, unconsciousness, delirious speech, fright syncope, or mania in the course of febrile disease. 4. Cautions and contraindications It is not applicable for patients diagnosed with qi and yin deficiency, slight dryness and stagnation, or for those who are aged and weak. It is forbidden to use for pregnant women. Avoid taking a high dose in order to prevent the zheng qi from being damaged.

Associated Formulas Xiăo Chéng Qì Tāng (Minor Purgative Decoction, ⼩承⽓汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. The decoction should be taken in two divided doses for warmly oral administration. Once the loose stool appeared, the use of decoction should be discontinued. [Actions] Expels heat bind by mild purgation. [Applicable Patterns] Mild cases of yangming bowel excess. Symptoms include: hard stool, abdominal pĭ and distention, delirious speech, tidal fever, a tough yellow

tongue coating, a slippery, rapid pulse, dysentery initially due to heat accumulating in the stomach and intestine, and abdominal urgency with rectal heaviness. Tiáo Wèi Chéng Qì Tāng (Stomach-Regulating and Purgative Decoction, 调胃承⽓汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. Dà huáng and zhì gān căo should be decocted first, dissolve máng xiāo in the strained decoction. [Actions] Expels heat bind with mild purgation. [Applicable Patterns] Interior binding of heat and dryness in a pattern of yangming bowel excess. Symptoms include: constipation, thirst, vexation, steaming fever delirious speech, a yellow tongue coating, a slippery, rapid pulse, macules, hematemesis, epistaxis, swollen and painful mouth, gums, and throat caused by exuberant heat in the stomach and intestines. Fù Fāng Dà Chéng Qì Tāng (Compound Formula Major Purgative Decoction, 复⽅⼤承⽓汤) [Source]

Treating Acute Abdominal Disease by Integrative Treatment (Zhōng Xī Yī Jié Hé Zhì Liáo Jí Fù Zhèng,中西医结合治疗急腹症) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Unblocks the interior by purgation, moves qi and invigorates blood. [Applicable Patterns] This formula may be used in the following biomedically defined disorder when the patient shows signs of yangming bowel excess pattern complicated by obvious abdominal pain and distention: simple ileus. Xiăo Chéng Qì Tāng, Tiáo Wèi Chéng Qì Tāng, and Fù Fāng Dà Chéng Qì Tāng are all formulas that are associated with Dà Chéng Qì Tāng. Dà huáng is included in all four formulas to purge heat so that yangming bowel excess is relieved. In Dà Chéng Qì Tāng, máng xiāo and dà huáng is the main medicinal pair. Dà huáng is added to the decoction near the end of the cook time and is combined with zhĭ shí and hòu pò rendering its purgative action strong. This drastic purgative formula is designed for serious yangming bowel excess manifested by pĭ, fullness, dryness, and excess. In Xiăo Chéng Qì Tāng, máng xiāo and zhĭ shí are removed, and the dosage of hòu pò is reduced. Moreover, dà huáng is decocted simultaneously with the other two medicinals, so it has milder purgative action. This “gentle

purgative formula”[6] is applicable to mild yangming bowel excess manifested by pĭ, fullness, and excess without obvious dryness. In Tiáo Wèi Chéng Qì Tāng, zhĭ shí and hòu pò are removed while gān căo is added. Gān căo moderates the purgative power of máng xiāo and dà huáng. Tiáo Wèi Chéng Qì Tāng is the mildest of these three formulas. It is used to treat yangming dryness-heat accumulation in the interior without pĭ or fullness. Fù Fāng Dà Chéng Qì Tāng is composed of Dà Chéng Qì Tāng (in which zhĭ shí is replaced by zhĭ qiào) plus lái fú zĭ, táo rén, and chì sháo. Its actions of moving qi, guiding out stagnation, invigorating blood, and dissolving stasis are strengthened enough to be used on those abdominal pain and distention patients who have serious yangming bowel excess.

Case Studies 1. Diarrhea transformed into a yangming bowel excess pattern A patient named Bai Yi-cai suffered from abdominal pain and diarrhea for a month and had taken countless shēng jiāng and fù zĭ during that time. He had a strong constitution and especially liked to eat meat. He was too confident in his strong body and therefore he did not control his diet when he developed diarrhea. He thereby finally developed a stomach excess pattern which often manifested symptoms such as constipation, spontaneous sweating, coma, delirious speech, mania, abdominal distention, a dry cracked yellowish tongue coating, cold body, a faint pulse with a deep cun that was hard to feel. On closer inspection, he was making a loud noise and moving his limbs restlessly. He was thirsty and desired cold water. Other symptoms such as insomnia and abdominal fullness assured me of the diagnosis of stomach excess. His cold body indicated extreme exuberant

heat outwardly separating from the yin. The faint pulse is the result of ying qi’s failure to distribute to the limbs because of heat bind block in the middle jiao. This is a case of an extreme yin syndrome resembling a yang syndrome. I immediately prescribed a dose of Dà Chéng Qì Tāng. But it didn’t work despite taking another three doses. Then I figured that the disease was actually caused by pathogens retained in the three yin channels. The notion was clearly justified by the faint cun pulses. I then added 3 qian fù zĭ to break yin in order to promote the balance of yin and yang. After taking only one dose of the prescription, the patient began to have watery stool; the cun pulses quickly grew strong, but the mania became unexpectedly more severe. I knew the yin pathogen was gone and it was the time to use Dà Chéng Qì Tāng alone, without fù zĭ. The condition improved a little and I continued with the formula for another three doses. Throughout the course of treatment, the disease was not relieved until a quarter kilogram of máng xiāo and a quarter kilogram of dà huáng were applied. This case proves that a three yin-cold syndrome may become very terrible when there is retained food generating yangming stagnation and dryness. 1 1 Qi Bing-hui. Qi’s Case Records 齐氏医案. Beijing: Chinese Publishing House of Traditional Chinese Medicine and Pharmacology; 1999. p. 55.

Comments: The patient had a strong constitution and took a lot of hot, acrid medicinals to treat diarrhea, but they generated dryness-heat. Moreover, he didn’t control his diet so dryness-heat combined with retained food in the stomach and intestines. The symptoms were signs of yangming bowel excess such as hard stool, abdominal distention, spontaneous sweat, delirious speech, mania, and a scorched tongue coating. Because the disease initially involved the three yin channels, the yincold pathogen had still not cleared completely which blocked yang qi from spreading. That is why the whole body became cold and the pulses were weak and thready. After drastic purgation removing yin-cold, the truth of yangming bowel excess was

revealed. The disease was then cured by promoting defecation with Dà Chéng Qì Tāng. This case teaches us two things. First, not all yangming bowel excess is caused by external contraction. Second, Dà Chéng Qì Tāng was used several times without a response, but if its indications are still there, it should continue to be used. 2. Convulsive syncope Once I treated a patient whose name was Jin Kui-guan in the Menghe district. He had a fever that could not be relieved after sweating. The other symptoms were abdominal pain, unclear mind, delirious speech, frequent convulsions, and a dry mouth. His tongue had a yellow coating along with a thick grey, greasy coating in the middle. After turning to other doctors in vain, he came to me. His deep, excessive, slippery pulses indicated yangming interior heat, which cannot be cured unless yin is saved by drastic purgation. After taking only one dose of a formula containing dà huáng (prepared with wine) 5 qian, máng xiāo 3 qian, zhĭ shí 1 qian, and hòu pò 1 qian, he had two normal bowel movements. Thereafter his fever cleared, consciousness restored, and convulsions ceased. Gradually he began to eat rice soup for two days before he began to feel hungry again. At that point he was cured. 1 Comments: Treating convulsive disease with Dà Chéng Qì Tāng is recorded in Essentials from the Golden Cabinet. In this case, the convulsions were caused by yangming exuberant drynessheat and bowel excess damaging body fluids and resulting in poor nourishment and convulsions of the tendons. Dà Chéng Qì Tāng treats convulsions by saving yin-fluids through drastic purgation. However, it tends to damage stomach qi so rice soup is eaten to boost stomach qi and promote fluid production following purgation.

Dà Huáng Mŭ Dān Tāng ⼤黄牡丹汤Rhubarb and Cortex Moutan Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Ingredients

Preparation and Administration 1 Wujin County Medical Association. Menghe Four Family’s Medical Texts: Fei Sheng-fu’s Consilia and Records 孟河四家医集·费绳甫医话医案. Nanjing: Dongnan University Publishing House; 2006.

Decoct the first four medicinals with water and thereafter add máng xiāo into the hot decoction.

Formula Indications Dà Huáng Mŭ Dān Tāng is indicated for the initial stage of intestinal abscess caused by the stagnation of dampness, heat, and blood stasis. The symptoms are pain which refuses pressure in the right lesser abdomen (lateral aspects of the lower abdomen), pain that can be as severe as strangury or even accompanied with swollen mass in the right lesser

abdomen, bent right foot which cannot stretch without the pain being worsened, normal urination, frequent fever, spontaneous sweating, and aversion to cold. The tongue coating is thin, greasy, and yellow. The pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis The binding of qi and blood causes this type of intestinal abscess. The pain that refuses pressure, as well as the swollen mass, is generated by damp-heat stagnating and blocking intestinal collaterals. Because the right foot is bent, unable to stretch open without increasing the pain, the disease can be concretized as “contracting foot intestinal abscess”. The pain may be as severe as strangury; yet the urination is normal, which differentiates it from strangury. Frequent fever, spontaneous sweating, and aversion to cold indicate that while there is qi and blood stagnation that has caused the abscess, ying and wei qi have become disharmonious. The greasy yellow tongue coating and rapid slippery pulses are signs of damp-heat. Intestinal abscesses caused by stagnation of dampness, heat, and blood stasis should be treated by draining heat and dampness, breaking up stasis, and dissolving the abscess.

Formula Actions Drains heat, breaks up stasis, dissipates masses, and relieves swollen sores.

Formula Analysis

Unique Combination Features This formula combines heat-draining and blood-invigorating medicinals to purge stasis and heat. It also combines the purgative method with the dampness-draining method in order to discharge damp-heat from urine and stool.

Further Clarification 1.Why does this formula use the purgative method to treat intestinal abscesses? The type of intestinal abscess that this formula treats is caused by dampness, heat, and blood stagnated in the intestines. As one of the six fu-

organs, the intestine functions properly when there is free flow. Once there is blockage, there is pain; and once there is free flow, the pain will be gone. To cure this disease, pathogens must be given an exit. Specifically, excess pathogens in the intestines must be cleared up through defecation. In Dà Huáng Mŭ Dān Tāng, máng xiāo and dà huáng are used to drain heat and promote defecation. They not only drastically remove pathogens by purging them but they also restore the free flow in the intestines so that the pain is relieved. 2.At what stage is an intestinal abscess to be indicated for this formula? It was recorded in the Essentials from the Golden Cabinet that “big and surging pulses tell of the formation of pus and the forbid to purge”[7]. However, in terms of using this formula, it also says that: “if there is pus, the pus should be purged; if there is no pus, static blood should be purged.”[8] This inconsistency led to disputes by later generations. Currently, the overwhelming opinion is all intestinal abscesses that are due to an excess stagnation of damp, heat, and blood can be treated with this formula no matter whether the pus is formed or not.

Formula Applications 1. Essential pattern differentiation Dà Huáng Mŭ Dān Tāng is commonly used to treat intestinal abscesses due to the stagnation of damp, heat, and blood stasis. This clinical pattern is marked by:

● pain which refuses pressure in the right lower abdomen ● yellow, greasy tongue coating ● rapid, slippery pulse

2. Modifications

3. Modern applications This formula is commonly used to treat acute simple appendicitis, intestinal obstruction, acute biliary tract infection, biliary ascariasis, pancreatitis, acute pelvic inflammation, and infections after oviduct ligation when the patient shows signs and symptoms of stagnation of dampness, heat, and blood stasis. 4. Cautions and contraindications Those whose abdominal abscess has been perforated, the elderly, pregnant, postpartum, or the weak should either not use it or use it with caution.

Associated Formulas Lán Wěi Huà Yū Tāng (Vermiform Appendix Stasis-Dissolving Decoction, 阑尾化瘀汤) [Source] New Research on Acute Abdominal Pain (Xīn Jí Fù Zhèng Xué, 新急腹 症学) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Moves qi and invigorates blood, clears heat and removes toxins. [Applicable Patterns] Initial stage of acute appendicitis due to stasis and stagnation. Symptoms include: fever, abdominal distention and pain, and local tenderness and rebounding pain in the right lower abdomen. The latter stage of appendicitis. Symptoms include: less obvious heat, abdominal distention, belching, and poor appetite. Lán Wěi Qīng Huà Tāng (Vermiform Appendix Heat-Clearing and Stasis-Expelling Decoction, 阑尾清化汤) [Source] New Research on Acute Abdominal Pain (Xīn Jí Fù Zhèng Xué, 新急腹 症学) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions]

Clears heat and removes toxins, moves qi and invigorates blood. [Applicable Patterns] The stages of heat accumulation or early pus formation in acute appendicitis or mild peritonitis. Symptoms include: low fever or afternoon fever, dry mouth and thirst, abdominal pain, constipation and yellow urine. Lán Wěi Jiě Dú Tāng (Vermiform Appendix Toxin-Resolving Decoction, 阑尾解毒汤) [Source] New Research on Acute Abdominal Pain (Xīn Jí Fù Zhèng Xué, 新急腹 症学) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and removes toxins, promotes defecation and dissipates masses, moves qi and invigorates blood. [Applicable Patterns] The stage of heat toxin in acute appendicitis. Symptoms include: fever and aversion to cold, red eyes and complexion, dry mouth, thirst and desire for water, nausea, abdominal pain which refuses pressure tension of the abdominal muscles, rebounding pain, constipation, a red tongue with a

yellow and dry or yellow and greasy coating, and a surging, big, slippery and rapid pulse. Lán Wěi Huà Yū Tāng, Lán Wěi Qīng Huà Tāng, and Lán Wěi Jiě Dú Tāng are new formulas created to treat acute appendicitis. They are based upon Dà Huáng Mŭ Dān Tāng and formulated based on modern research. Lán Wěi Huà Yū Tāng uses qi-moving and blood-invigorating medicinals as its main components and uses auxiliary ingredients to clear heat, remove toxins, and unblock the interior through purgation. It moves qi and invigorates blood as well as clears heat and removes toxins. Therefore it is applicable to either the initial stage of appendicitis due to stasis and stagnation or the last stage of appendicitis when the pain is gone. Lán Wěi Huà Dú Tāng uses heat-clearing and toxin-removing medicinals as its main components and uses auxiliary ingredients to move qi, invigorate blood and unblock the interior through purgation. It is good at clearing heat and removing toxins as well as moving qi and invigorating blood. Therefore it is applicable to the heat accumulating stage of appendicitis, the early stage of pus formation, or mild peritonitis. Lán Wěi Jiě Dú Tāng uses heat-clearing, toxin-removing, massdispersing, and purgative medicinals as its main components and uses auxiliary ingredients to move qi and invigorate blood. It has a special function to clear heat and remove toxins, promote defecation and disperse masses as well as move qi and invigorate blood. Therefore, it is applicable to heat toxin stage of acute appendicitis.

Case Studies Intestinal abscess1

Case 1: A patient whose surname was Shi came to my clinic. He had an intestinal abscess that was not cured despite taking many purgative treatments. One day before he saw me, his abdominal distention was partially relieved after taking Dà Huáng Mŭ Dān Tāng prescribed by a Dr. Jiang. However, when he visited me, his condition still needed to be treated by purgation. I prescribed the previous formula, Dà Huáng Mŭ Dān Tāng, with some modifications as follows: shēng dà huáng (added later) 5 qian, dōng guā zĭ 1 liang, táo rén 80 pieces, mŭ dān pí 1 liang, dāng guī 5 qian, máng xiāo (infused) 3 qian, chì xiăo dòu 4 liang (decocted alone and then added into the former decoction). The second visit: After taking the formula he excreted sticky, red stool that contained neither pus nor blood. I speculated that this kind of muddy stool must be the filth and turbid from within the intestines. After the patient took the decoction, I could hear water gurgling noisily inside his intestines. It clearly told that there must be stagnation blocking the intestines. This was the so-called abscess; an abscess generated by blocking. If the block was not removed, how could abscess be cured? Because the disease root was still there, the previous prescription was continued at a smaller dose: shēng dà huáng 3 qian, mŭ dān pí 5 qian, táo rén 50 pieces, dāng guī 5 qian, dōng guā rén 1 liang, chì sháo 5 qian, bài jiàng căo 5 qian, máng xiāo (infused) 2 qian, chì xiăo dòu 4 liang (decocted alone and then added into the former decoction). The third visit: Although his intestinal sludge had been diluted with the purgative therapy, he still had tenderness below the umbilicus in the right lesser abdomen. That was because the root of the disease was still there; therefore, the previous prescription was continued with shēng dà huáng and máng xiāo removed to moderate the purgative action: mŭ dān pí 1 liang, dōng guā zĭ 1 liang, yì yĭ rén 1 liang, táo rén 5 qian, bài jiàng căo 5 qian,

shēng gān căo 2 qian, dāng guī 5 qian, jié gĕng 3 qian decocted in a soup made of chì xiăo dòu 4 liang. The fourth visit: The intestinal abscess was nearly cured. 1 Cao Ying-fu. Records of Experiments with Classical Formulas 经⽅实验录. Shanghai: Shanghai Scientific and Technical Publishers; 1979. p. 90-93.

Comments: The intestinal abscess was very stubborn and was not resolving even with repeated purgation. This happened because the root of the disease was still intact. An abscess develops due to the accumulation of prolonged stagnation of dampness, heat, and turbid pathogens; therefore, it cannot be removed in one stroke. Here Dà Huáng Mŭ Dān Tāng was used with an addition of bloodharmonizing, stasis-dissolving, heat-clearing, dampness-draining, and toxin-removing medicinals to remove all the dampness, heat, stasis, and toxins. Although the root was not completely cleared up, pathogenic qi had already been reduced after many purges. Máng xiāo and dà huáng were removed in the third prescription to protect the zheng qi since it may become damaged. The fourth prescription was intended to clear up the remaining pathogens by using heat-clearing, dampness-draining, stasisdissolving and toxin-removing medicinals. Case 2: Once a patient named Lu Zuo came to see me when he had pain in the right abdomen, one cun below and lateral to umbilicus. His right foot was contracted to point where he could not extend the foot without causing himself a lot of pain. According to Western medicine he had appendicitis. His pulse was big and excessive. I prescribed: shēng dà huáng 5 qian, máng xiāo 3 qian, táo rén 5 qian, dōng guā rén 1 liang, mŭ dān pí 1 liang. The second visit: His pain lessened a little, but he still could not stretch out his right foot without aggravating the pain. I prescribed him Sháo Yào Gān Căo Tāng: bái sháo 5 qian, chì sháo 5 qian, shēng gān căo 3 qian, rŭ xiāng 3 qian, mò yào 3 qian.

The third visit: He was able to stretch the right foot but the pain remained. I continued using Dà Huáng Mŭ Dān Tāng to promote defecation: shēng dà huáng 1 liang, máng xiāo (infused) 7 qian, táo rén 5 qian, dōng guā rén 1 liang, mŭ dān pí 1 liang. Comments: The pain was located one cun lateral and below to the umbilicus in the right lower abdomen. This is an area where intestinal abscesses commonly occur. The big, excessive pulse indicated an exuberant pathogen stagnating in the interior. I concluded that there was an abscess caused by stagnation of dampness, heat, and stasis and prescribed Dà Huáng Mŭ Dān Tāng to treat it. However, in order to specifically address the contracted right foot, the prescription was changed to Sháo Yào Gān Căo Tāng with added rŭ xiāng and mò yào to dissolve stasis, relax the spasms, and relieve pain. However, there was still pain although the foot was able to relax out of the contraction. This indicated that pathogenic dampness, heat, and stasis were still there and Dà Huáng Mŭ Dān Tāng should be continued. This case illustrates the importance of syndrome of pulse diagnosis in regards to syndrome differentiation and the therapeutic order when addressing the root and branch of disease patterns. It is a lesson worth learning from.

Dà Xiàn Xiōng Tāng ⼤陷胸汤Major Chest Draining Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Ingredients

Preparation and Administration Dà huáng is first decocted with water. Then after, infuse máng xiāo and gān suì powder into the decoction.

Formula Indications Dà Xiàn Xiōng Tāng is indicated for thoracic accumulation caused by the binding of water and heat. The symptoms are pain that refuses pressure below heart, hardness in the diseased location, or there is a full, hard, and painful region below the heart and above the lesser abdomen and touching is not tolerated. Other accompanying symptoms are shortness of breath, vexation, constipation, and mild tidal fever in the afternoon. The tongue is red with a yellow greasy or watery coating, and the pulse is deep and tight or deep, slow, and powerful.

Analysis of Fundamental Pattern Pathogenesis This pattern is an excessive pattern caused by the binding of pathogenic heat with retained fluids. These two pathogens stagnate and form a hard, painful mass that refuses pressure below heart. The hard and painful region may even extend to a wider area from below the heart to above the lesser abdomen, and no touching is tolerated. When water and heat bind in the stomach and intestines, it leads to constipation, mild tidal fever in the afternoon, or shortness of breath and vexation. The bind also prevents the body fluids from spreading upward, so there is dry mouth and thirst. The red tongue with a yellow greasy coating and deep, tight, powerful pulses are signs of the water and heat bind in the interior. Draining heat and expelling water treat this type of syndrome.

Formula Actions Drains heat and expels water through purgation.

Formula Analysis

Unique Combination Features

This formula is a drastic prescription that combines the heat-draining and water-expelling by purgation methods. It treats both water and heat by enabling their discharge through the stool.

Further Clarification What is the purpose for dà huáng being decocted ahead of the other ingredients? According to the indications of this formula, the location of this disease is as high as in the chest. Dà huáng is decocted ahead of others to reduce its purgative power as is instructed by the therapeutic principle, “treating disease located high up in the body with mild”[9].

Formula Applications 1. Essential pattern differentiation Dà Xiàn Xiōng Tāng is the most common formula used for major chest bind syndrome. This clinical pattern is marked by:

2. Modern applications This formula is usually applied for acute pancreatitis, acute ileus, pyogenic liver abscess, exudative pleurisy, and cholecystitis and cholelithiasis due to binding of water and heat. 3. Cautions and contraindications Do not use this formula for those who have a weak constitution or weakness after illness. It should not be overused in order to prevent it from

harming the zheng qi.

Comparison & Contrast Dà Chéng Qì Tāng vs. Dà Xiàn Xiōng Tāng

Case Studies Thoracic accumulation A 14-year-old child named Chen suddenly got ill one day. He had a surging, big pulse, high fever, dry mouth, spontaneous sweating, and his right foot was contracted and unable to stretch. His illness was caused by a yangming disorder. He had thirst without a desire to drink, congested sensation in the chest, which was neither swollen nor hard. It seemed like an

ache that would be caused by pleural rheum. Given the fact that he had not defecated for five days, it was clear that the patient had dampness up in the chest and dryness down in the intestines. It must have been a simultaneous occurrence of taiyang dampness entering chest and yangming heat accumulating in the interior. The problem was how could dryness-heat be cleared up without draining damp-phlegm. I prescribed Dà Xiàn Xiōng Tāng consisting of gān suì prepared) 1.5 qian, dà huáng 3 qian, and máng xiāo 2 qian. After taking the decoction, dry stool and phlegm-drool were discharged and his symptoms were significantly alleviated. I then prescribed one dose of a heat-clearing prescription for him to take in order to eliminate the remaining pathogens.1 Comments: Symptoms such as high fever, dry mouth, spontaneous sweating, constipation, and a big, surging pulse are signs of dryness-heat exuberance in the yangming channel. Thirst without a desire to drink and the congested sensation in the chest, which is neither swelling nor hard but as painful as aching caused by pleural rheum, are caused by inhibited qi movement due to phlegm-drool blocking the chest. The cause of this particular case is gastrointestinal dryness-heat steaming and concentrating fluid into phlegm-drool in the chest. Therefore, Dà Xiàn Xiōng Tāng was applied to drain dryness-heat from the yangming channel and expel phlegm rheum from the chest. After taking it, all of the symptoms were relived.

Section 2 Warm Purgative Formulas Warm purgative formulas are applicable to excess patterns of cold accumulation in the interior. The signs and symptoms include constipation, pain in the abdominal and stomach cavities, cold hands and feet, or even reversal cold of the hands and feet, and a deep, tight pulse, etc. The cold pathogen cannot be removed unless warming is applied and stagnation will not be expelled unless purgation is used. Therefore, purgative medicinals such as dà huáng and máng xiāo are combined with interior warming ingredients such as fù zĭ, gān jiāng, or xì xīn to form the basic structure of a prescription. For those whose spleen yang is deficient, rén shēn and gān căo, sweet-warm medicinals that boost qi, are added to address the deficiency. Representative formulas of this chapter are Dà Huáng Fù Zĭ Tāng and Wēn Pí Tāng.

Dà Huáng Fù Zĭ Tāng ⼤黄附⼦汤Rhubarb and Aconite Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) 1 Cao Ying-fu. Records of Experiments with Classical Formulas 经⽅实验录. Shanghai: Shanghai Scientific and Technical Publishers; 1979. p. 69.

Formula Ingredients

Preparation and Administration Prepare Dà Huáng Fù Zĭ Tāng as a decoction.

Formula Indications This formula is designed for an excess pattern of cold stagnation in the interior. The symptoms are abdominal pain, constipation, rib-side pain, fever, reversal cold of the hands and feet, a white and greasy tongue coating, and a wiry, tight pulse.

Analysis of Fundamental Pattern Pathogenesis This is an excessive pattern caused by yin-cold and stagnation blocking the intestines. The interior excess yin-cold prevents yang qi from warming and flowing freely, which causes qi and blood to become blocked. The symptoms include abdominal pain and reversal cold of the limbs; and when cold accumulation blocks the qi of the intestines, there is constipation. The white, greasy tongue coating and wiry, tight pulse are also evidence of excess cold. Warming the interior, dissipating cold, promoting defecation, and expelling accumulation treat the interior excess cold accumulation.

Formula Actions Warms the interior, dissipates cold, promotes defecation, and relieves pain.

Formula Analysis

Unique Combination Features This formula is recognized as the quintessence of warm purgation because it treats cold and excess simultaneously by combining the methods of warming the interior with purgation.

Further Clarification 1.Why is dà huáng, a medicinal with a bitter and cold property, included in this formula when its action is to expel cold accumulation? While this formula contains bitter and cold dà huáng, it still maintains its action to warmly purge. This is because dà huáng is combined with the extremely hot and acrid fù zĭ, which in this formula, is dosed at the largest amount found within the Treatise on Cold Damage. In addition, it is combined with warm xì xīn. Dà huáng’s cold property is constrained by hot medicinals and only its action to expel accumulation through purgation remains. This method of combination is called “disregard properties and utilize the actions”[10]. 2.Why is it that the fever is not caused by excess heat?

According to the indications of this formula, the fever is caused by yang qi constrained by interior binding caused by cold accumulation. The tongue’s coating can differentiate this pattern, which is greasy rather than dry and yellow. Fever is not always a product of excess heat.

Formula Applications 1. Essential pattern differentiation Dà Huáng Fù Zĭ Tāng serves as the representative warm purgation prescription and is a common formula used to treat excess patterns of constipation due to cold accumulation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of interior excess cold accumulation: acute appendicitis, acute ileus, swollen and painful testis, cholecystalgia, post cholecystectomy syndrome, chronic dysentery, and uremia. 4. Cautions and contraindications This formula is prohibited to use in patterns of interior excess due to heat. The dosage of dà huáng is not supposed to surpass that of fù zĭ.

Case Studies Chronic abdominal pain A patient named Zhong Da-man reported having abdominal pain for years. He had taken formulas such as Lĭ Zhōng Wán (Center-Regulating Pill) and Sì Nì Tāng (Frigid Extremities Decoction) to stop the pain, however the pain would come and go irregularly. It could come many times during a month or even just once in two months after eating cold food or drinking cold water. He often drank ginger soup with pepper powder to relieve it. One day when I was visiting a relative’s family, I was told of his strange disease and was asked to treat him. The patient had a deep, wiry, and tight pulse and a light-red, moist tongue without coating. Pressing on the abdomen elicited a mild pain that radiated to the rib-side and low back. He had one bowel movement every two days with only a little dry stool; his urination was normal. I told him that: “The disease is caused by an accumulation of yincold that cannot be expelled unless it is both warmed and purged simultaneously. The formulas you took did not work because they merely removed cold without expelling accumulation. My prescription will cure your illness in two doses.” He answered: “I’ve heard that you are famous for treating cases of prolonged disease. If you can really cure my disease I will be forever grateful.” Prescription: Dà huáng 12 g, zhì fù zĭ 9 g, xì xīn 4.5 g. I also told him: “This formula is an effective prescription proven by countless practice. Your confidence should not waiver because of other people’s opinions.” Six months later, I met him again and he told me that he was cured with two doses as I expected. 1 Comments: Prolonged abdominal pain incurred by eating cold food and/or drinking cold water, mild pain with pressure, small amounts of dry

stool, a moist white tongue coating, and a deep tight pulse resemble the symptoms of abdominal pain due to deficient cold in spleen and kidney. However, Lĭ Zhōng Wán and Sì Nì Tāng did not relieve the pain. This indicated that the pain was caused by cold accumulation rather than deficient cold. Lĭ Zhōng Wán and Sì Nì Tāng can disperse formless cold but not concrete cold accumulation. Dà Huáng Fù Zĭ Tāng can warm the interior, expel accumulation through purgation, and remove both cold and accumulation simultaneously. Therefore I was very certain of its good efficacy within two doses.

Wēn Pí Tāng 温脾汤Spleen-Warming Decoction Source Text Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng,备急千⾦要⽅)

Ingredients

Preparation and Administration Prepare Wēn Pí Tāng as a decoction. 1 Zhao Shou-zhen. Memories of Treating Diseases 治验回忆录. Beijing: People's Medical Publishing House; 1962.

Formula Indications Wēn Pí Tāng is indicated for cold accumulation due to yang deficiency. Symptoms are abdominal pain and constipation, unstoppable colic around umbilicus, cold hands and feet, a white tongue coating with no thirst, and a deep wiry, slow pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by spleen yang deficiency with internal obstruction due to cold accumulation. Constipation and colic around the umbilicus are caused by the obstruction of bowel qi due to excessive cold accumulation within the intestines. The hands and feet lack warmth, there is mental fatigue, and a lack of strength because of the loss of warmth and nourishment due to spleen yang deficiency. The white tongue coating, lack of thirst, and the slow, deep, wiry pulse are evidence of yang deficiency and cold accumulation. The proper therapeutic method is to remove the cold accumulation through purgation and warm and supplement spleen yang.

Formula Actions Expels cold accumulation through purgation, warms and supplements spleen yang.

Formula Analysis

Unique Combination Features Two therapeutic methods, warming and purgation, are combined within this formula. In addition, this formula combines the attacking with supplementing methods. While the attacking method is the stronger function, it purges without harming zheng qi and supplements without restraining pathogens.

Formula Applications 1. Essential pattern differentiation

Wēn Pí Tāng serves as the common formula applicable to deficient spleen yang and interior retention of cold accumulation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of deficient cold of middle yang and interior retention of cold accumulation: acute simple ileus, incomplete ileus, or uremia. 4. Cautions and contraindications Wēn Pí Tāng is forbidden for use in patients with heat accumulation and interior excess or yin and blood deficiency.

Comparison & Contrast Dà Huáng Fù Zĭ Tāng vs. Wēn Pí Tāng

Case Studies 1. Intermittent dysentery I treated a patient who suffered from intermittent dysentery for almost five years. He had an occasional painful mass in his abdomen, dysentery with some dry stool, a wiry and slow pulse, and a grey tongue coating. All of these symptoms were signs of both deficiency and cold accumulation. In Experiential Formulas (Bĕn Shì Fāng, 本事⽅), it was said that gastrointestinal cold accumulation causing diarrhea and abdominal pain should be treated by purgation before supplementing deficiency. Pathogens should not be kept due to fear of worsening deficiency. This is the situation in this particular case. As I gave him a prescription, I told him “this formula is for your reference, take it if you are confident in me.”

Prescription: Rén shēn xū 3 qian, fù zĭ (prepared) 3 qian, gān jiāng (fried) 2 qian, gān căo 1.5 qian, dāng guī (prepared with wine) 1.5 qian, dà huáng (prepared with wine) 3 qian, zhĭ shí (prepared with soil) 3 qian, and xuán míng fĕn 2 qian were ground into fine powder and then mixed with honey water to make pills. Each dose is 3 qian of the pills swallowed with Shā Rén decoction.1 Comments: Intermittent dysentery is usually caused by the coexistence of deficiency and excess. In this case, the patient had dysentery for nearly five years, a mass in abdomen, dysentery with dry stool, a wiry and slow pulse, and a grey and white tongue coating. The dysentery is caused by cold accumulation due to deficiency and coldness in spleen and stomach. So Wēn Pí Tāng with zhĭ shí was used to warm yang, disperse cold, and remove cold accumulation through purgation. If spleen yang is not recovered after the removal of cold accumulation, then Lĭ Zhōng Tāng (Center-Regulating Decoction, 理中汤) or Fù Zĭ Lĭ Zhōng Tāng (Aconite Center-Regulating Decoction, 附⼦理中汤) is used to warm the middle, disperse cold, harmonize and supplement the spleen and stomach to promote recovery. Considering his weak constitution, purgation must not be abandoned because otherwise dysentery cannot be cured if the accumulation still exists. 2. Abdominal pain 1 Wang Xu-gao. Case Records of Wang Xu-gao’s Clinical Practice 王旭⾼临证医案. Beijing: People's Medical Publishing House; 1987. p. 43.

I once treated a patient who suffered unbearable distention and colic around the umbilicus. He also complained of dizziness, coldness of the body with chills, and irregular cold and hot sensations. He had a deep, thready pulse on the left hand and a surging, slippery, wiry pulse on the right, a weak constitution, and food retention in the stomach and intestines. He did not respond well to formulas that move qi, remove stagnation, and relieve pain.

In his case the suitable method should be to combine cold with warmth; therefore Wēn Pí Tāng, a prescription from Important Formulas Worth a Thousand Gold Pieces (Qiān Jīn Yào Fāng, 千⾦要⽅) was applied. The prescription consisted of fù zĭ, gān jiāng, dà huáng, máng xiāo, dăng shēn, dāng guī, and gān căo. After taking this prescription the coldness was eliminated and the pain was alleviated. This suggested the efficacy of this prescription. But the occurrence of a dry mouth, thirst, purple lips, and a yellow tongue coating indicated heat. So then I changed the prescription into a mild formula that used bitter and acrid flavors to clear and descend heat, but the pain remained as before. But even worse, he stopped defecating and urinating and began to have abdominal distention, borborygmus, palpitations, nausea, thirst and desire for hot water, serious insomnia, and occasional teeth gnashing. The pain would be relieved after meals or it needed to be strongly pressed when severe and his right hand pulse was powerful and slippery. I gave him two more doses of Wēn Pí Tāng, and he discharged a lot of loose stool. I also prescribed a compress for his abdomen made with wheat bran fried with vinegar and the pain gradually cleared. Finally, I used Hòu Pò Wēn Zhōng Tāng (Officinal Magnolia Bark CenterWarming Decoction, 厚朴温中汤) and Wŭ Líng Săn (Five Substances Powder with Poria, 五苓散) to warm the middle and promote urination and then the patient was cured. 1 Comments: Symptoms such as colic and distention around the umbilicus, coldness of the body with chills, a deep thready pulse on the left and a surging, slippery and wiry pulse on the right are caused by spleen yang deficiency, cold accumulation retaining in the interior, and yang constraint. Formulas that move qi and stagnation and relieve pain can only move the stagnation rather than dissipate the cold. Since cold coagulation cannot be dissipated, those formulas were not efficacious. Utilizing Wēn Pí Tāng to

warm yang, disperse cold, promote defecation, and remove accumulation is the correct solution. However the heat symptoms, which came up after taking the formula, occurred because of the spreading of yang qi due to the gradual dissipation of yin coagulation and not an adverse event stemming from wrong treatment. When I changed the prescription to clear and descend heat with bitter and acrid medicinals, the yang qi closed again and the disease worsened. Therefore Wēn Pí Tāng had to be used again to relieve the pain. In the last step, Hòu Pò Wēn Zhōng Tāng and Wŭ Líng Săn were used to warm the middle, move qi, transform qi and promote urination so that the disease is cured.

Section 3 Moistening Purgative Formulas Moistening purgative formulas are used to treat constipation due to intestinal dryness and fluid deficiency. The signs and symptoms are dry stool, scanty and yellow urine or frequent urination, a dry yellow tongue coating, and a rapid pulse. These formulas combine common moistening purgative medicinals such as má zĭ rén, xìng rén, yù lĭ rén, and băi zĭ rén with medicinals that drain heat and promote defecation such as dà huáng and máng xiāo. If the constipation is caused by kidney essence deficiency it will present with dry stool, clear and profuse urine, soreness and weakness of the lower back and knees, cold limbs, a pale tongue covered with white coating, and a deep and slow pulse. These formulas combine common medicinals that warm the kidney, boost essence, and moisten the intestines, such as ròu cōng róng, niú xī, and dāng guī, with medicinals that raise the clear and direct turbid downward, such as shēng má, zhĭ qiào, and zé xiè. Common formulas in this category are Má Zĭ Rén Wán and Jì Chuān Jiān.

Má Zĭ Rén Wán 麻⼦仁丸Cannabis Fruit Pill a.k.a Pí Yuē Wán (Spleen Confinement Pill, 脾约丸) Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) 1 Lu Zhao-lin. Conserving Case Records Now and Then, extracted from Chinese Case Records Categorized Compilation in All Ages《医案偶存》,录⾃《中国古今医案类编》. Beijing: Chinese Constructional Material Industrial Publishers; 2001.

Formula Ingredients

Preparation and Administration Grind the above medicinals and make them into honey pills. Take 9 g of the pills each time with warm water. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratio. Mix the decoction with honey.

Formula Indications Má Zĭ Rén Wán is indicated for spleen confinement constipation due to dryness-heat in the stomach and intestines. The symptoms are dry stool, frequent urination, a red tongue body, a dry slightly yellow tongue coating, and a rapid pulse.

Analysis of Fundamental Pattern Pathogenesis The pathomechanism is spleen yin deficiency due to dryness-heat in the stomach and intestines. This syndrome was called “spleen confinement” (pí yuē, 脾约) in the Treatise on Cold Damage. “Confinement” means constraint and restriction. The spleen moves the stomach fluid upward and down to spread it to every corner of the body. When there is dryness-heat in the

stomach and intestines, spleen yin is damaged. The spleen becomes too dry to move the stomach fluid so the fluids are not able to spread normally. Instead it pours down to the bladder in the form of frequent urination. The loss of moistening and descending within the intestines also causes dry stool because of the confinement. The rapid pulse and red tongue covered by dry, yellow coating are evidence of dryness-heat in the stomach and intestines. The therapeutic principles used to remedy this pattern are to moisten the intestines, drain heat and promote defecation.

Formula Actions Moistens the intestines, drains heat, and moves qi to promote defecation.

Formula Analysis

Continued

Unique Combination Features This formula contains Xiăo Chéng Qì Tāng, a formula that drains heat and promotes defecation. It also contains medicinals that promote fluid production and moisten the intestines such as má zĭ rén, xìng rén, sháo yào, and honey. It is distinguished from other common formulas that moisten the intestines in order to promote defecation because it combines moistening with purgation. The moistening will not be too greasy, and the purgation will not be harmful to the zheng qi.

Further Clarification 1.Why is xìng rén used in this formula to diffuse and descend the lung qi? Given the interior-exterior relation between the large intestine and the lung, the descending and free flowing action of the intestines relies on the diffusing and descending action of the lung qi. If the lung qi can descend and diffuse freely, the intestine will descend and flow freely as well, and the

defecation will be normal. This formula promotes defecation by diffusing the lung and descending qi. 2.How is this formula prepared and administered? The purgation should be mild and moistening because the dryness-heat in the stomach and intestines is mild without signs of serious excess such as pĭ and fullness or distention and pain of the abdomen or stomach cavity. In this scenario the most suitable method of preparation is the honey pill because honey is sweet, moistening, and mild in function. In the original method of administration, only ten pills the size of a parasol tree seed are taken three times per day initially. If the efficacy is not obvious, the dosage can increase until defecation is restored to normal.

Formula Applications 1. Essential pattern differentiation Má Zĭ Rén Wán serves as the common formula used to treat spleen confinement syndrome due to dryness-heat in the stomach and intestines, deficiency of spleen fluid; and, as the representative prescription of the moistening purgative category. This clinical pattern is marked by:

● dry stool ● frequent urination ● slightly yellow and dry tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of dryness-heat in the stomach and intestines and fluid consumption: constipation in weak individuals due to intestinal dryness of the aged, habitual constipation, postpartum constipation and hemorrhoids, and postoperative constipation. 4. Cautions and contraindications It is not applicable to the aged, the weak, fluid inadequacy, blood insufficiency, or deficiency spleen and stomach without dryness-heat. Pregnant women should use it with caution.

Associated Formulas Wŭ Rén Wán (Five Kernels Pill, 五仁丸) [Source] Effective Formulas from Generations of Physicians (Shì Yī Dé Xiào Fāng, 世医得效⽅) [Ingredients]

[Preparation and Administration]

Grind the five kernels into paste and chén pí into powder, add honey, and make them into pills the size of phoenix tree seed. Take 9 g with warm water 1-2 times per day. [Actions] Moistens the intestines to promote defecation. [Applicable Patterns] Deficiency constipation due to fluid exhaustion and intestinal dryness. Symptoms include: dry stool, constipation due to blood deficiency in the elderly and postpartum, a dry tongue with scanty fluid, and a thin, choppy pulse. Wŭ Rén Wán resembles Má Zĭ Rén Wán because they are both able to moisten the intestines to promote defecation, but it is unique in the way that Wŭ Rén Wán combines five oily seeds with chén pí, which can regulate qi and move stagnation. When moistening purgation is combined with qimoving medicinals, it can treat constipation due to deficient intestinal fluid by moistening and lubricating the dry intestines. Má Zĭ Rén Wán primarily contains medicinals that supplement yin and moisten the intestines such as má zĭ rén, xìng rén, fēng mì, and sháo yào. It also contains Xiăo Chéng Qì Tāng, a formula that can drain heat and remove stagnation. The combination of supplementation with draining and purgation with moistening allows for its application to half deficient and half excess spleen confinement constipation due to dryness-heat in the stomach and intestines and deficient spleen fluid.

Case Studies Constipation

Mr. Liu, 28 years old, had dry stool that he would excrete with great difficulty once every five or six days. He had to push so hard that even his clothes were soaked with sweat and his lips became dry. After he would repeatedly lick his lips to moisten them, his lips were covered over with a shell as thick as a scab that would leave lesions and bleed if peeled. Given his deep slippery pulse and dry yellow tongue coating, the syndrome is caused by spleen confinement syndrome with a strong stomach and weak spleen. The spleen flourishes on the lips so when there is spleen deficiency, the lips become dry and cracked. I cured his constipation by prescribing Má Zĭ Rén Wán alone. 1 Comments: The spleen has its orifice in the mouth and it flourishes on the lips. Symptoms such as dry stool accompanied by dry cracked lips, a dry yellow tongue coating, and a deep slippery pulse are indications of “spleen confinement” syndrome caused by gastrointestinal dryness-heat and deficiency of spleen yin. So the disease in this case was easily cured with Má Zĭ Rén Wán alone.

Jì Chuān Jiān 济川煎Fluid-Replenishing Decoction Source Text The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书)

Ingredients

Preparation and Administration Prepare Jì Chuān Jiān as a decoction.

Formula Indications This formula is indicated for deficiency of kidney yang, essence, and blood. The symptoms are dry stool, clear and profuse urine, soreness and weakness of lower back and knees, dizziness, a pale tongue with a white coating, and a deep, slow and weak pulse.

Analysis of Fundamental Pattern Pathogenesis

1 Liu Du-zhou. Popular Explanation of Treatise on Cold Damage 伤寒论通俗讲话. Shanghai: Shanghai Scientific and Technical Publishers; 1980.

This is a pattern of constipation caused by the weakness of kidney yang, deficiency of essence and blood, and a disorder of the opening and closing aspect of the kidney. The kidney governs the five fluids, has its orifice in urethra and anus, as well as controls urination and bowel movement. Deficient kidney yang cannot control qi transformation so that fluids cannot spread. They then flow down to the unconfined bladder and turn into clear and profuse urine. The loss of fluids spreading into the large intestine and the deficiency in essence and blood may cause the intestines to lose moisture and inhibit their descending ability making the stools too dry to be expelled. Other symptoms such as soreness and weakness of lower back and knees, dizziness, a pale tongue body with a white coating, and a deep, slow or deep, thready pulse are evidence of deficient kidney yang, essence and blood. The therapeutic principles used to remedy this pattern are to warm the kidney and supplement the essence, as well as, moisten the intestines to promote defecation.

Formula Actions Warms the kidney and supplements essence, moistens the intestines to promote defecation.

Formula Analysis

Unique Combination Features This formula primarily warms the kidney and supplements essence, and it also moistens the intestines to promote defecation. Jì Chuān Jiān combines supplementation with draining and descending with rising.

Formula Applications 1. Essential pattern differentiation Jì Chuān Jiān serves as the most commonly prescribed formula for constipation due to kidney and essence deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of kidney and essence deficiency: habitual constipation, senile constipation, and postpartum constipation. 4. Cautions and contraindications It should not be used to treat constipation caused by pathogenic heat damaging fluids or by yin deficiency.

Case Studies Constipation Case 1: I have treated a woman who was nearly 40 years old, postpartum, and had a weak constitution. After the labor, she had scanty lochia, which stopped too soon, and dry stool that was very hard to be discharged. The conclusion of her lochia was caused by yin deficiency, which was evident, by her deep and weak pulse. This situation can by explained through metaphor — if a boat is stuck, grounded, on a dry river

bed, it can not sail along with the current even though it is being pushed hard. If purgative medicinals that break qi stagnation are used by mistake, the original qi is further damaged. Her symptoms and pulse only showed the existence of deficiency. Therefore, nourishing blood and moistening the intestines to relieve constipation is as effective as pouring water into the river in order to sail the stuck boat. I prescribed her modified Jì Chuān Jiān. Prescription: Dāng guī 1 liang, shú dì huáng 1 liang, ròu cōng róng 3 qian, gŏu qĭ zĭ 3 qian, huái niú xī 3 qian, zé xiè 3 qian, huŏ má rén 2 qian, and zhì gān căo 1 qian. After taking two doses, her defecation became easy and normal. She was then cured with ten doses of Dà Bŭ Yuán Jiān (Major Original Qi-Supplementing Decoction, ⼤补元煎) one month later. 1 1 Wang Xin-hua. Chosen Cases from Generations of Famous Physicians 中医历代医话精选. Nanjing: Jiangsu Scientific and Technical Publishers; 1998.

Comments: The patient’s weak constitution, labor at an advanced age, deficiency of yin and blood, and the loss of moistening and descending in the intestines led to constipation since evacuating her stool was as hard as sailing a boat in a dried-up river. The scanty lochia and deep, weak pulse were sound evidence of yin and blood deficiency. Jì Chuān Jiān, a formula designed for constipation due to deficiency of kidney, essence, and blood was used with shēng má and zhĭ qiào removed in order to reduce its action of raising and breaking qi. Medicinals that can nourish yin-blood and moisten the intestines were added to moisten the intestines and promote defecation. Such a method serves to promote defecation by supplementing, which is similar to pouring water into a dried river in order to sail a boat that has become stuck. There are many reasons for constipation and this case illustrated that purgation should not be used abruptly in all kinds of constipation without second thought.

Case 2: Mrs. Zhao, a 78-year-old retired cadre came to my clinic for an initial visit on November 23rd, 1998. She complained that over the past five years she had been suffered from refractory constipation. The constipation would come and go although the dry stool could sometimes be excreted with great difficultly when using purgatives such as Má Zĭ Rén Wán and fān xiè yè. Over the past three weeks her constipation was aggravated by abdominal distention and pain, poor appetite, occasional headache, vexation, and poor sleep. She also had a pale red tongue with a thin, dry white tongue coating, and a thready, wiry pulse. Her disease was diagnosed as senile constipation caused by deficient original qi failing to conduct and transmit. Boosting qi, moistening intestines, and descending qi to unblock the bowels is the proper method of treatment for this type of syndrome. Therefore I prescribed modified Jì Chuān Jiān containing shēng huáng qí 15 g, dāng guī 15 g, táo rén 15 g, quán guā lóu 15 g, chuān niú xī 15 g, jú huā 15 g, zhĭ shí 15 g, xìng rén 10 g, ròu cōng róng 10 g, shēng bái zhú 30 g, and xuán shēn 30 g to be decocted with water, taken one dose per day. The second visit: Her constipation was a little relieved after taking 6 doses, but the abdominal distention, pulses, and tongue were the same as before. Therefore, I continued the prescription but added wine prepared dà huáng 6 g for 8 doses. The third visit: Her defecation became normal, the abdominal distention and pain were relieved, the headache was gone, and her sleep and appetite improved and her spirit was better than before. Her tongue was still pale red and her pulse was still thready. So I continued the prescription without dà huáng for 6 doses. The fourth visit: Her condition was steady with no relapse. I suggested that she drink more water and do more exercise. 1

Comments: Given the advanced age of the patient and chronic nature of her constipation, there must have been the coexistence of deficiency and excess. This had manifested as deficiency of qi, blood, yin, and essence along with dryness-heat in the stomach and intestines. When there is qi deficiency, the patient has no strength to discharge stool. When there is yinblood deficiency, the intestines are not moistened and cannot descend. When there is dryness-heat in the intestines, the unblocking and purgative functions are affected. Therefore, there are symptoms such as constipation, abdominal pain and distention, headache, and vexation.

Section 4 Water-Expelling Purgative Formulas 1 Yang Ming-hui. Selected Cases from Zhao Guan-ying’s Experience 赵冠英验案精选. Beijing: Academy Press; 2003.

Water-expelling purgative formulas are used for patterns of excess water accumulation in the interior. The signs and symptoms are water retention in the hypochondrium, chest and hypochondriac radiating pain caused by coughing and spitting, or edema and abdominal distention, difficulty in defecation and urination, and an excessive and forceful pulse. The method of percolating and draining dampness with bland medicinals is not effective to treat these patterns and symptoms. Rather, the drastically purging water accumulation method should be used to discharge water through defecation and urination. Common medicinals found within the expelling water by purgation formulas include dà jĭ, yuán huā, and gān suì. Because the medicinals that constitute the formulas that expelling water through purgation have toxicity, these formulas often contain dà zăo to nourish the stomach and supplement zheng qi. Shí Zăo Tāng is the common formula in this category.

Shí Zăo Tāng ⼗枣汤Ten Jujubes Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration The first three medicinals are ground into powder and then filled into capsules. Take 0.5-1 g of the capsules with a decoction made of 10 pieces of dà zăo, one time per day in the morning before having breakfast. After defecation, eat porridge to promote recovery.

Formula Indications This formula is used for pleural rheum with chest and hypochondriac radiating pain caused by coughing and spitting. There is also hardness and distention below the heart, belching, shortness of breath, headache, dizziness, pulling pain resulting in breathlessness, a slippery tongue coating, and a deep and wiry pulse. It is also indicated for edema all over the body, especially in the lower half of the body, with abdominal distention, panting, and difficult defecation and urination.

Analysis of Fundamental Pattern Pathogenesis The types of edema and pleural rheum that can be treated by this formula are caused by excessive water that has accumulated in the chest and rib-side and blocks the movement of qi. This is the reason that there is pain in the chest and rib-side with radiating pain caused by coughing and spitting and pulling pain that inhibits deep breathing. Water that is oppressing the lung prevents lung qi from diffusing which causes shortness of breath and coughing. Water that is retained below heart causes qi to stagnate in the

center. The stomach’s harmonizing and descending function begins to fail and leads to belching as well as hardness and distention below the heart. Pathogenic fluid obstructs clear yang and inhibits it from rising, which leads to headaches and dizziness. Pathogenic water overflows at the surface in the skin layer and accumulates in the organs, preventing qi from moving freely and causing it to stagnate in the sanjiao. The patient thereby develops systemic edema, abdominal distention, panting, and difficult defecation and urination. A white, watery tongue coating, as well as a deep and wiry pulse, are indications of water accumulating in the interior. This type of syndrome cannot be cured by the ordinary method of dissolving rheum and promoting urination; it is necessary to expel water through purgation as fast as possible.

Formula Actions Expels water by purgation.

Formula Analysis

Further Clarification

1.An explanation of the combination of gān suì, dà jĭ, and yuán huā First, they are all medicinals that expel water through drastic purgation. Each medicinal expels water from a different location; therefore, the function to expel is strengthened and the effected region is expanded. Second, each of the three medicinals is toxic, but in different aspects. When they are combined, the dosage of each single ingredient is reduced, which means that each individual medicinal’s toxin is also reduced. This is an example of the principle: “combining medicinals with the same function can increase the overall toxicity; while combining medicinals with differing toxicities will reduce the overall toxicity.” 2.Why is gān căo not used to reduce toxicity, fortify the spleen, and protect the stomach? The combination of gān căo with gān suì, dà jĭ, or yuán huā creates an antagonistic pair. Gān căo, a versatile antidote, will increase the toxicity unexpectedly if it is combined with these three medicinals instead of detoxification.

Formula Applications 1. Essential pattern differentiation Shí Zăo Tāng serves as the representative prescription used to expel water through drastic purgation and is the most common formula prescribed for pleural rheum and excess edema. This clinical pattern is marked by:

2. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of a pattern of excess water retention in the interior: exudative pleurisy, tuberculous pleurisy, cirrhosis and chronic nephritis causing hydrothorax, ascites, or systemic anasarca and ascites due to terminal schistosomiasis. 3. Cautions and contraindications First, dà jĭ, gān suì, and yuán huā should be made into powder rather than being decocted with water. Second, the formula should be taken only one time before breakfast in the morning. It should be used temporarily rather than being used for a long time. The dosage is supposed to be small initially. If the water cannot be expelled at the small dosage, then gradually increase the dosage up to 3 g. Third, when there is diarrhea after taking it, eat rice porridge to nourish the stomach qi. Last, this formula is only applicable to patients who have sufficient zheng qi and an excess pathogen. Those who are weak or aged should use it with caution. For patients with deficient zheng qi and excess pathogen, the water cannot be drained unless this formula is used in tandem with qi-boosting, spleen-fortifying, and stomach-harmonizing formulas; or sequentially with either supplementation or attacking first. It is important to note that this formula is forbidden to use for those with deficient edema or for those women who are pregnant.

Associated Formulas Kòng Xián Dān (Drool-Controlling Pill, 控涎丹) [Source] Treatise on Diseases, Patterns, and Formulas Related to the Unification of the Three Etiologies (Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn, 三因极⼀病证 ⽅论)

[Ingredients]

[Preparation and Administration] Grind the medicinals into powder and make them into pills the size of phoenix tree seed. Take 1-3 g with warm water in the morning. [Actions] Dispels phlegm and expels water. [Applicable Patterns] Phlegm lodged in the chest and diaphragm. Symptoms include: sudden and unbearable, dull pain in the chest, back, neck and hip, pulling and wandering pain in tendons and bone, cold limbs, unbearable headaches, unconscious, fatigue, or sleepiness, poor appetite, sticky saliva, sputum gurgling in the throat at night, profuse drooling, a sticky, greasy tongue coating, and a wiry, slippery pulse. Shū Záo Yĭn Zĭ (Dredging and Piercing Drink, 疏凿饮⼦) [Source] Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction.

[Actions] Expels water through purgation, disperses the interior to scatter wind. [Applicable Patterns] Exuberance of water accumulation. Symptoms include: systemic edema, panting, thirst, uroschesis and constipation, and a deep, excessive pulse. Shí Zăo Tāng, Kòng Xián Dān, and Shū Záo Yĭn Zĭ are all waterexpelling formulas that can be used to treat excess water accumulating in the interior. Shí Zăo Tāng is applicable for pleural rheum caused by water accumulating in the chest and rib-side as well as excess patterns of abdominal distention due to edema because it drastically expels water through purgation. The symptoms are pain in the chest and rib-side, a white, watery tongue coating, and a deep, wiry pulse. Kòng Xián Dān is Shí Zăo Tāng with yuán huā and dà zăo removed and bái jiè zĭ added. Bái jiè zĭ is good at dispelling phlegm-drool located between the skin and membrane or in the chest and diaphragm; it has a special ability to dispel phlegm and expel water. Since Kòng Xián Dān is prepared as a pill, it works more mildly and slowly. It is most often prescribed for patients with phlegm-drool and water accumulation experiencing dull pain in the chest and diaphragm with a sticky, greasy tongue coating, and a slippery, wiry pulse. Shū Záo Yĭn Zĭ combines shāng lù, a medicinal that expels water through purgation, with medicinals that promote urination, percolate dampness, scatter wind, and release the exterior so that the water is drained via urination, defecation, and perspiration. It is applicable for systemic edema, uroschesis, and constipation due to exuberant water accumulation in the interior that is overflowing in the exterior.

Case Studies 1. Edema Mr. Wen’s wife, who was 40 years old, suffered from systemic edema for half a year after giving birth to her seventh baby. Before this visit, she received many unsuccessful treatments. Her symptoms included a veinspreading abdomen as big as a drum, systemic edema, emaciation, pale complexion, emotional fatigue, poor appetite, spitting phlegm-drool, scanty urine, unformed stool, a pale tongue with white coating, and a weak pulse. I prescribed her a formula that can fortify the spleen, dissolve stagnation, and warm yang to move water. After taking it, the abdominal distention was relieved a little and her appetite grew, but the disease remained uncured. One night she was tempted by the smell of preserved meat that was on her family’s night snack table. She asked for some and ate it with two bowels of gruel. After the meal, she was unable to digest it, so she came to my clinic in an emergency right after dawn. She had unbearable abdominal distention that made her unable to stay calm. She couldn’t remove the food by vomiting or defecation and could breathe only by raising her shoulders with difficulty. Her pulse was slippery and rapid, and her tongue coating was white and greasy. This disease was caused by water retention and an uncontrolled diet damaging the stomach and spleen. Her condition could not be relieved unless water was expelled through purgation as quickly as possible, so Shí Zăo Tāng was applied immediately. Prescription: Dà jĭ, gān suì, and yuán huā were dosed in equal proportions, fried with vinegar, and then ground into a fine powder. Then finally, 1.5 g of the powder was infused with a decoction made from ten pieces of dà zăo. I gave her two packs of powder, 1.5 g each, and instructed her to take one pack first. If she didn’t have diarrhea then she should take the

other pack a half-day later. Unexpectedly she took the two packs at one time because her husband was afraid that the dosage is too small to relieve her severe disease. Consequently, she had unstoppable pouring diarrhea. Frightened, her family sent her to my clinic. Due to unstoppable diarrhea, I had to ask her to lie still with a toilet pan under her bottom while I prescribed her a large dose of rén shēn and huáng qí to be decocted into a thick decoction for frequent intake. After discharging one pot of filthy water, her edema gradually dissipated. I then prescribed medicinals that supplement and regulate the spleen and stomach in order to promote recovery.1 1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Physician: Zhang Qi’s Medical Cases 中国现代名中医医案精华. Beijing: Beijing Publishing House; 1990.

Comments: Labor is usually accompanied by weakness. In this case the patient had edema after delivering many babies and her abdomen was big with distended veins all over it. She also had symptoms of spleen yang deficiency and unhealthy transportation and transformation. Her disease was caused by spleen yang deficiency and water retention and it needed to be treated with formulas that warm yang and move water in order to treat it slowly rather than attacking and expelling the water abruptly. But then the indigestion worsened the water stagnation and she could not be cured without drastic purgation. But her family was naive and impatient for her condition to improve, which is why her husband gave her double the prescribed dosage at one time. Consequently she had severe diarrhea that was nearly unstoppable without the help of rén shēn and huáng qí. These two medicinal were used at a large dosage to rescue qi from collapsing. After being purged the spleen was so weak that spleen and stomachregulating formulas had to be used as the final step. This case deserves to be studied because of the urgent treatment of the branch done before the root. 2. Water retention

Zhang Ren-fu first came to my clinic with palpitations caused by water attacking the heart. When the water accumulates under the rib-side, there is local pain. When the water overflows to the chest, there is chest distention and a wiry pulse. If the syndrome is caused by rheum then there will also be vomiting and shortness of breath. In this case, it must be Shí Zăo Tāng syndrome. Prescription: Yuán huā (prepared) 5 fen, gān suì (prepared) 5 fen, and dà jĭ 5 fen ground into a fine powder and infused with a decoction made from 10 pieces of black jujube. The prescription is to be taken in two doses.1 Comments: Fluid retention is a yin pathogen with a watery nature that flows all around without staying in a fixed location. Therefore, the symptoms caused by it are highly diverse. For example, rib-side pain, chest distention, palpitation, belching, and shortness of breath accompanied by wiry pulses on both sides are signs of pleural rheum. Pleural rheum cannot be removed by the common liquid-dissolving and water-expelling formulas; Shí Zăo Tāng is applied to expel water through purgation.

Section 5 Formulas that Reinforce Zheng Qi and Purge Pathogenic Factors 1 Cao Ying-fu. Records of Experiments with Classical Formulas 经⽅实验录. Shanghai: Shanghai Scientific and Technical Publishers; 1979.

Formulas that reinforce zheng qi and purge pathogenic factors are prescribed for syndromes with interior excess and zheng qi deficiency. The signs and symptoms are constipation, stomach cavity and abdominal distention with co-existing qi and blood deficiency or exhausted yin-fluid. In such patterns, the zheng qi will be further damaged if the interior excess is not expelled by purgation. The deficient zheng qi will not recover if the supplementing method is not applied; yet interior excess will worsen if only the supplementing method is used. Therefore, the only way to address the pattern comprehensively is to combine the attacking method with supplementing method. The main principle of these formulas is the combination of medicinals that purge such as dà huáng and máng xiāo with medicinals that supplement such as rén shēn, dāng guī, shēng dì, xuán shēn, and mài dōng. Huáng Lóng Tāng is the common formula in this category.

Huáng Lóng Tāng 黄龙汤Yellow Dragon Decoction Source Text Six Texts on Cold Damage (Shāng Hán Liù Shū, 伤寒六书)

Formula Ingredients

Preparation and Administration Prepare Huáng Lóng Tāng, without the máng xiāo, as a decoction; then infuse jié gĕng 3 g, shēng jiāng 3 pieces, dà zăo 2 pieces, and the máng xiāo into the decoction.

Formula Indications This formula may be prescribed for yangming bowel excess with deficiency of qi and blood. This pattern is characterized by either the discharge of clear, watery stool that is pure green or constipation. There is stomach cavity and abdominal distention and pain which refuses pressure, fever, thirst, mental fatigue, shortness of breath, delirious speech, picking at their pajamas, grabbing at the air as if arranging thread, unconsciousness, reversal counterflow cold of the four limbs, a dry yellow or dry black tongue coating, and a weak pulse.

Analysis of Fundamental Pattern Pathogenesis Binding of interior pathogenic heat, dry stool obstructing bowel qi, and deficiency of qi and blood are the cause of this pattern. Pathogenic heat enters the interior and combines with the dry stool in the intestines to create bowel qi obstruction. This causes constipation, stomach cavity and

abdominal distention, pain which refuses pressure, fever, thirst, a dry yellow or black tongue coating. There may also be discharge of clear, watery stool that is pure green, the typical symptom of heat retention with watery discharge due to yangming bowel excess. When the patient has a constitution of qi and blood deficiency or prolonged excess interior heat that failed to be treated on time, and thereafter exhausts qi and blood, he or she may have mental fatigue, shortness of breath, and a weak pulse. Exuberant heat harasses the mind causing mental disorder and zheng qi collapsing, resulting in dangerous symptoms such as unconsciousness, delirious speech, reversal counterflow cold of the four limbs, and picking at pajamas. Given the two aspects of interior excess and zheng qi deficiency, treatments should involve draining heat and removing stagnation through purgation, as well as, boosting qi and nourishing blood.

Formula Actions Purges by promoting defecation, supplements qi and nourishes the blood.

Formula Analysis

Unique Combination Features This formula is the combination of Dà Chéng Qì Tāng with medicinals that boost qi and nourish the blood, such as rén shēn and dāng guī. The main action of Huáng Lóng Tāng is to remove heat bind through purgation. It also supplements the qi and nourishes the blood so that the purgation will not damage the zheng qi. Furthermore, due to the unique combination of purging medicinals with supplementing medicinals, the supplementing method will not retain the interior pathogens.

Further Clarification

As a formula with Dà Chéng Qì Tāng as a main aspect of its construct, why is dà huáng is not added later as it is in Dà Chéng Qì Tāng? Although this syndrome is marked by interior excess due to heat bind, qi and blood is so deficient that the zheng qi is on the edge of collapsing. If the purgation is too strong, it is very likely that the original qi will collapse. So when purgation is used, measures should be taken to prevent zheng qi from collapsing; people should be protected when pathogens are attacked. That is why dà huáng is not added later as it is in Dà Chéng Qì Tāng. This formula is milder than Dà Chéng Qì Tāng in its purgative action.

Formula Applications 1. Essential pattern differentiation Huáng Lóng Tāng serves as the representative prescription that combines the attacking method with the supplementing method. It is the common formula used to treat yangming bowel excess with concurrent deficiency of qi and blood. This clinical pattern is marked by:

2. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of the coexistence of yangming bowel excess and deficiency of both qi and blood: abdominal typhus, paratyphoid fever, epidemic cerebrospinal meningitis, epidemic type B encephalitis, and senile intestinal infarction.

3. Cautions and contraindications It is forbidden to use for patients with constipation due to cold accumulation or deficiency of qi, yin, and blood.

Associated Formulas Xīn Jiā Huáng Lóng Tāng (Newly Supplemented Yellow Dragon Decoction, 新加黄龙汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare Xīn Jiā Huáng Lóng Tāng without the rén shēn and ginger juice as a decoction as 3 cups. Take 1 cup with rén shēn 5 fen and two spoonful ginger juice each time. Once the loose stool appeared, the use of decoction should be discontinued. [Actions] Drains heat to promote defecation, nourishes yin and boosts qi. [Applicable Patterns] Interior excess due to heat bind, deficiency of qi and yin. Symptoms include: constipation, distention, fullness and hardness in abdomen, mental

fatigue, shortness of breath, dry mouth, cracked lips, a dry, cracked tongue, and a dry yellow or black tongue coating. Xīn Jiā Huáng Lóng Tāng and Huáng Lóng Tāng are both formulas that drain heat bind through purgation as well as boost qi and nourish blood. Xīn Jiā Huáng Lóng Tāng expels heat bind mildly with Tiáo Wèi Chéng Qì Tāng and utilizes medicinals that nourish yin and increase fluids such as xuán shēn, shēng dì, mài dōng, and hăi shēn in large amounts in order to supplement the fluids so the “water can sail the boat”. It is commonly applied for chronic interior excess caused by heat bind that has not been expelled effectively with the purgative method used alone. Given the prolonged duration of the disease, the zheng qi has been consumed and the yin-fluids have become exhausted. In this pattern, the heat bind is not as serious as the exhausted yin-fluids. Huáng Lóng Tāng preserves yin by drastically purging heat accumulation via Dà Chéng Qì Tāng; simultaneously, it also supplements qi and blood deficiency. Therefore, it is applied in patterns of yangming bowel excess that have not been treated fast enough to avoid qi and blood consumption. The pathomechanism of Huáng Lóng Tāng is serious heat bind with concomitant qi and blood deficiency.

Case Studies 1. Yin summerheat In Guizhou Province I have treated a patient whose surname was Wu. He had slept in a cool place after having dinner. When he awoke the next morning, he had a headache, aversion to cold, high fever, no sweating, a tight pulse, and a tongue coating that was white on the edges and yellow in the center. My diagnosis was the coexistence of yin summerheat and food accumulation. I prescribed Huò Xiāng Zhèng Qì Săn modified by removing bái zhú and adding xiāng rú. However, his condition didn’t improve with

this prescription. He visited another doctor who questioned my diagnosis, “summerheat is yang in nature, how comes there is yin summerheat?” Seeing the high fever, the doctor prescribed Bái Hŭ Tāng modified by adding lú gēn and lián qiào. The first dose of this prescription seemed to be somewhat effective, so he continued with it. However, he developed delirious speech, unconsciousness, frequent nausea, and a grey-black tongue coating. The doctor saw this change as the pathogen entering the pericardium and continued the previous prescription adding xī jiăo, huáng lián, and Zĭ Xuĕ Dān. However his emergent condition was not relieved at all, so he turned to me again. His pulse was stronger on the right in both shape and strength, so I suggested that the pathogens are still staying at the qi level and not reversely transmitting into the pericardium. He still had the grey-black, thick tongue coating, high fever, unconsciousness, delirious speech, and vomiting. I thought to myself that the pathogen must be retained because of the cold medicinals and cannot be removed without warming and dispersing. So I prescribed Yì Yuán Săn (Original Qi-Boosting Powder, 益元散) with added xìng rén, xiè bái, dà dòu juăn, huò xiāng, shén qū, kòu rén, xiāng rú, and zhĭ qiào. After taking the first dose, his fever increased. After another dose, he sweat all over his body and his high fever was completely alleviated. When I saw him the next time, he was still having unconsciousness and delirious speech. His tongue coating was even drier and his right hand pulse was strong and excessive under pressure. I figured that his pulse, fluids, and mind should return to normal after sweating and relieving the high fever. However, the opposite condition must now exist due to the dry stool retained in the stomach. Since the exterior pathogen had been cleared, it was appropriate to purge. Therefore, I prescribed Huáng Lóng Tāng but replaced máng xiāo with xuán míng fĕn, and replaced rén shēn with xī yáng shēn.

Half a day after taking the decoction, the patient had his clothes changed and all the symptoms suddenly disappeared. Thereafter I used the spleenawakening and yin-nourishing methods to cure his disease gradually over several days. 1 1 Lei Feng. Treatise on Seasonal Diseases 时病论. Taiyuan: Shanxi Scientific and Technical Publishers; 1992.

Comments: After sleeping in a cool place on a hot summer night the patient had a headache, aversion to cold, high fever, inability to sweat, a tight pulse, and a tongue coating that was white on the edges and yellow in the center. These were symptoms of summerheat constraining the lung channel at the qi level and wind-cold constraining the fleshy exterior. In this case, there were three mistakes. First, the treatment should have started with Xīn Jiā Xiāng Rú Yĭn, which can expel wind cold exteriorly and clear summerheat interiorly. But, the warming and dampness-dissolving method with acrid medicinals was used instead by mistake. Second, using the heavy dosage of Bái Hŭ Tāng, which is acrid and cold, when the exterior pattern was still present, caused the exterior cold to be retained. This prevented the cold from dispersing exteriorly and aggravated the interior heat. When interior heat generates dryness-heat and attacks upwards, there is unconsciousness, delirious speech, frequent nausea, and a grey-black tongue coating. Third, the unconsciousness caused by the upward attack of drynessheat in the yangming channel was mistaken as heat attacking the pericardium and medicinals such as xī jiăo, huáng lián, and Zĭ Xuĕ Dān were added improperly. When the pathogen is still in the exterior and interior yangming channel excess is formed, the treatment principle should be to relieve the exterior before attacking the interior. Therefore, after taking a warming and dispersing formula, the patient sweat and his fever cleared. Patients suffering with febrile disease will normally have their mind restored and pulses calmed once the fever is cleared, but this patient still had unconsciousness,

an even drier tongue coating, and a powerful excess pulse. This was because the yangming interior excess was not removed and it began to exhaust qi, blood, and fluids. So I then, prescribed Xīn Jiā Huáng Lóng Tāng with rén shēn replaced with xī yáng shēn. The patient was rescued from this dangerous condition through the combination of the purgative method, which expelled the interior heat bind, with the supplementing method, which boosted qi, nourished blood, and promoted the production of fluids. 2. Constipation Mrs. Li, 70 years old, came to my clinic for the first time on July 14th, 1957. She was suffering with refractory constipation, thirst, desire for water, abdominal distention, pĭ and fullness, dizziness, weakness, yellow and burning urination, a red tongue body with a dry yellow coating, and a surging, rapid pulse on the right guān positioin. Her constipation was caused by heat and yin deficiency in the stomach, prolonged exhaustion of intestinal fluids, and the generation of interior heat. I prescribed Zēng Yè Chéng Qì Tāng (Humor-Increasing and Qi-Guiding Decoction, 增液承⽓汤) and modified Huáng Lóng Tāng, which can both attack and supplement by moistening the intestines, opening the blocked, and clearing stomach heat. Prescription: Dăng shēn 15 g, mài mén dōng 15 g, xuán shēn 12 g, shēng dì huáng 15 g, dāng guī 10 g, hòu pò 10 g, dà huáng (added later) 10 g, xuán míng fĕn (diffused with the decoction) 10 g, shí hú 12 g, shí gāo (decocted first) 30 g, qīng pí 10 g, huŏ má rén (fried and crushed) 12 g, tiān huā fĕn 12 g, jié gĕng 12 g, decocted with water, three doses. By the fourth day, her disease was greatly alleviated despite that her constipation, abdominal distention, pĭ and fullness, tongue coating, and pulse were still the same as before. These symptoms indicated that this disease was serious, so I addressed them immediately by modifying the previous

prescription by removing jié gĕng, shēng dì huáng, and mài mén dōng and adding jiāo sān xiān 12 g, bīng láng 10 g, and lái fú zĭ 10 g decocted with water, two doses. Three days later, her defecation normalized and all the other symptoms disappeared. Her disease did not relapse in the following six months. 1 1 Wang Guo-qing. Wang Xi-zhang’s Case Record 王锡章医案. Guiyang: Guizhou Scientific and Technical Publishers; 2001.

Comments: Refractory constipation, abdominal distention, pĭ and fullness, yellow burning urination, a red tongue body with a yellow tongue coating were caused by interior excess due to dryness-heat. Thirst, desire for water, and the dry tongue coating were indications of exhausted fluids. Dizziness and weakness were due to deficient qi and blood. The surging, rapid right guān pulse, which is the pulse location of the spleen and stomach, showed exuberant heat in the stomach. So Huáng Lóng Tāng with zhĭ shí replaced by qīng pí was used to drain heat and remove stagnation through purgation, as well as, to boost qi and nourish blood. Zēng Yè Tāng with added huŏ má rén, shí hú, and tiān huā fĕn was also applied to nourish yin, supplement fluids, and moisten the intestines with added shí gāo, a stomachclearing and fire-draining medicinal. Though the prescription was effective to some extent, the dryness-heat and accumulation was still retained in the stomach and intestines. Therefore, it was modified with aromatic dampdissolving medicinals and by adding medicinals that can move qi and remove food stagnation. Using the method, the disease was finally resolved.

Summary There are nine formal formulas and eleven associated formulas within the purgative formulas chapter. They are categorized into five types of purgative formulas:

● cold purgative formulas ● warm purgative formulas ● moistening purgative formulas ● water-expelling purgative formulas ● formulas that reinforce zheng qi and purge pathogenic factors 1. Cold purgative formulas This method is used for patterns of excessive interior heat and stagnation causing constipation, abdominal distention and pain, a thick yellow tongue coating, and an excessive pulse. The formulas that clear heat bind through purgation are Dà Chéng Qì Tāng, Dà Huáng Mŭ Dān Tāng, and Dà Xiàn Xiōng Tāng. Dà Chéng Qì Tāng is a representative formula that drastically purges heat accumulation. It contains raw dà huáng as its chief medicinal. It is added to the decoction later after boiling the other medicinals that increases its purgative action. This formula has a drastic ability to purge and is suitable for patients who have all the symptoms of an excess yangming bowel presentation: pĭ, fullness, dryness, and excess. Dà Huáng Mŭ Dān Tāng specializes in draining heat and breaking up stasis. It is used as the main formula to treat intestinal abscess caused by damp-heat and blood stasis. Dà Xiàn Xiōng Tāng contains dà huáng and gān suì as its main combination. It has the main focus to drain heat and remove stagnation. Therefore, it is used as a common formula to treat major chest bind syndrome caused by the accumulation of water and heat below the heart. 2. Warm purgative formulas This method is used for patterns of interior excess cold accumulation with stomach cavity and abdominal distention and fullness, abdominal pain that is relieved by warmth, cool limbs, and a deep, tight pulse. Both Dà

Huáng Fù Zĭ Tāng and Wēn Pí Tāng clear cold accumulation. They also both contain fù zĭ and dà huáng to warm the channels, dissipate cold, and promote defecation through purgation. Dà Huáng Fù Zĭ Tāng is a representative warm purgative formula used for constipation caused by excessive interior cold accumulation. Wēn Pí Tāng warms and supplements spleen yang. It is designed to address constipation caused by deficient spleen yang with cold accumulation in the interior. 3. Moistening purgative formulas This method is used for constipation due to intestinal dryness and with fluid damage causing constipation, yellow urine, fever, dry mouth, a red tongue body with a yellow coating, and a slippery rapid pulse. Má Zĭ Rén Wán and Jì Chuān Jiān both moisten the intestines to promote defecation. Má Zĭ Rén Wán combines Xiăo Chéng Qì Tāng with medicinals that moisten the intestines. It combines purgation with moistening and is thereby used to treat constipation caused by gastrointestinal dryness-heat and fluid deficiency. This is also referred to in the Essentials from the Golden Cabinet as spleen confinement syndrome. Ròu cōng róng is the chief medicinal in Jì Chuān Jiān. It warms the kidney and supplements essence, as well as, moistens the intestines to promote defecation. It is used in combination with medicinals that raise the clear and direct the turbid downward to produce a “combined supplementing and purgative formula” that treats constipation due to kidney essence deficiency. 4. Water-expelling purgative formulas This method is used for interior excess water accumulation with chest and rib-side radiating pain, edema and abdominal distension, disturbance of urination and defecation, and an excessive, forceful pulse. Shí Zăo Tāng combines medicinals that drastically expel water with dà zăo, a medicinal

that fortifies the spleen and revives the center. It can treat pleural rheum and excess edema by expelling water while it fortifies the spleen and zheng qi. 5. Formulas that reinforce zheng qi and purge pathogenic factors This method is used for constipation caused by interior excess with zheng qi deficiency. The main symptoms are abdominal fullness, constipation, and deficiency of blood and qi. Huáng Lóng Tāng combines Dà Chéng Qì Tāng, which is a formula that removes heat bind through purgation with medicinals that supplement qi and nourish blood. This combination allows Huáng Lóng Tāng to reinforce zheng qi and purge pathogenic factors. It is used to treat patterns of yangming bowel excess with qi and blood deficiency.

Questions 1.What are the different roles that dà huáng plays in Dà Chéng Qì Tāng, Dà Huáng Mŭ Dān Tāng, Dà Huáng Fù Zĭ Tāng, and Má Zĭ Rén Wán? 2.What combinations are used in the formulas designed to treat patterns of interior excess due to heat bind? 3.Dà Chéng Qì Tāng and Xīn Jiā Huáng Lóng Tāng both utilize dà huáng and máng xiāo to treat interior excess heat bind damaging yin. Why are they combined with zhĭ shí and hòu pò in Dà Chéng Qì Tāng and with qisupplementing and yin-nourishing medicinals in Xīn Jiā Huáng Lóng Tāng? 4.What are the differences between Má Zĭ Rén Wán and Jì Chuān Jiān in terms of their primary combination of medicinals, actions, indications, and pathomechanisms?

Endnotes: [1] 其下者，因⽽竭之︔中满者，泻之于内 [2] 痞、满、燥、实 [3] 峻下之剂 [4] 通因通⽤ [5] 寒因寒⽤ [6] 轻下之剂 [7] 脉洪⼤者，脓已成，不可下也 [8] 有脓当下，如无脓当下⾎ [9] 治上者治宜缓 [10] 舍性取⽤

CHAPTER 3 Formulas that Harmonize Formulas that harmonize have the therapeutic actions to harmonize the shaoyang, regulate and harmonize the liver and spleen, and regulate and harmonize the stomach and intestines. They are used to treat patterns of cold damage entering the shaoyang, disharmony of the liver and stomach, and disharmony of the stomach and intestines. The harmonizing method is one of the “eight treatment methods” recorded in ancient literature. The original formulas that harmonize were designed to treat cold damage entering the shaoyang, which belongs to the gallbladder and is located at half the exterior and half the interior. The sweatpromoting, emetic, and purgative methods are all inappropriate for this pattern. The only appropriate treatment is to harmonize. Since the gallbladder is attached to the liver through its interior-exterior relationship, disease of the gallbladder channel can affect the liver. The liver channel can also be affected by the gallbladder; furthermore, liver and gallbladder disease can also involve the spleen and stomach. Binding cold and heat caused by center qi deficiency may cause disharmony of the stomach and intestines. In addition to harmonizing the shaoyang to treat shaoyang syndrome, formulas that harmonize also regulate and harmonize the liver and spleen to treat disharmony of liver and stomach caused by liver stagnation and spleen deficiency, and regulate and harmonize the stomach and intestines to treat

disharmony of the stomach and intestines caused by binding cold and heat. Harmonizing formulas are categorized into three types:

● formulas that harmonize the shaoyang ● formulas that regulate and harmonize the liver and spleen ● formulas that regulate the stomach and intestines The composition and compatibilities of the harmonizing formula are unique because they do not use excessively cold or excessively hot medicinals, as well as, strong supplementation or strong drainage. Most often they simultaneously dispel pathogens and reinforce zheng qi, simultaneously vent the exterior and clear the interior, and simultaneously soothe the liver and rectify the spleen. These formulas are frequently used for complicated indications because of their even nature, gentle action, and comprehensive effects. However, formulas that harmonize primarily dispel pathogens. Therefore, they should not be used for purely deficient syndromes in order to prevent damage to the zheng qi. On the contrary, since they do address the zheng qi, they should not be used in patterns of pure excess in order to avoid detaining the pathogenic factor.

Section 1 Formulas that Harmonize the Shaoyang Formulas that harmonize the shaoyang are used to treat cold damage in the shaoyang level. The signs and symptoms include alternating chills and fever, fullness and discomfort in the chest and ribside, no desire to eat or drink, vexation and frequent vomiting, bitter taste in the mouth, dry throat,

dizzy vision, and a wiry pulse. Common medicinals used to harmonize the shaoyang are chái hú, qīng hāo, and huáng qín. When patients have a shaoyang pattern combined with a qi deficiency pattern, medicinals that boost qi and reinforce zheng qi may be used to prevent the pathogen from sinking. When they have a shaoyang pattern combined with a pattern of dampness, medicinals that percolate dampturbidity should be used to drain the pathogen. Common formulas in this category are Xiăo Chái Hú Tāng, Dà Chái Hú Tāng, Hāo Qín Qīng Dăn Tāng and Dá Yuán Yĭn.

Xiăo Chái Hú Tāng ⼩柴胡汤Minor Bupleurum Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration

Decoct the seven medicinals with 12 sheng of water. Boil down to 6 sheng, remove the dregs, and boil further until 3 sheng of water is left. Take 1 sheng of the warm decoction 3 times a day. (Modern use: prepare as a decoction.)

Formula Indications 1.Cold damage entering the shaoyang. The symptoms are alternating chills and fever, fullness and discomfort in the chest and rib-side, no desire to eat or drink, vexation and frequent vomiting, bitter taste in the mouth, dry throat, dizzy vision, a thin white tongue coating, and a wiry pulse. 2.Heat entering the blood chamber (uterus). The symptoms are feminine wind-invasion syndrome, inhibited menstrual flow, periodic alternating chills and fever, malaria, and jaundice when the patient shows signs of a shaoyang pattern.

Analysis of Fundamental Pattern Pathogenesis The shaoyang channel passes through the chest and covers the rib-side, and is located between the taiyang and yangming. When cold damage invades the shaoyang, which belongs to half-exterior half-interior, struggle between pathogenic qi and zheng qi causes alternating chills and fever. The foot shaoyang channel starts from the inner canthus, a branch enters the chest and diaphragm, connects the liver and gallbladder, and circulates though the rib side of body. Pathogens constrained in the shaoyang transform into heat. Gallbladder fire harasses the upper body, which causes fullness and discomfort in the chest and rib-side, vexation, a bitter taste in the mouth, dry throat, and dizzy vision. When gallbladder heat invades the stomach, it leads to the failure of the stomach qi to harmonize and direct

counterflow downward. This causes qi to rise and the patient may lose their desire to eat or drink and develop frequent vomiting and a bitter taste in the mouth. If women contract wind pathogens during their menstrual period, the combination of the inward transmission of pathogenic heat with blood stasis may cause their qi to flow irregularly, cease their menstruation and develop periodic alternating chills and fever. The sweating method can be used to release exterior pathogens, and the emetic and purgative methods are applicable for interior pathogens. However, since the pathogen is located at half exterior and half interior, the sweating, emetic, and purgative methods are all inappropriate. Only the harmonizing method can be used.

Formula Actions Harmonizes the shaoyang.

Formula Analysis

Continued

Xiăo Chái Hú Tāng is a harmonizing formula. It typically resolves patterns without sweating. Some patients do sweat after taking the formula and then feel better because of the recovery of their zheng qi, a release of pathogens, and a harmonization of the stomach qi. As the Treatise on Cold Damage said, “When the upper jiao is unblocked, the fluid descends, which brings harmonization of stomach qi, then the symptoms alleviated by drizzly sweating.”[1] If zheng qi is injured by an erroneous treatment for shaoyang syndrome or is often insufficient, shiver sweating (sweating after shivering and fever) may occur after taking this formula. It is a positive sign that zheng qi is conquering the pathogen.

Unique Combination Features This formula regulates the gallbladder and stomach simultaneously, but is focused on the gallbladder. It regulates the qi and fluids simultaneously, but it primarily rectifies qi. It simultaneously addresses the zheng qi and the pathogens, but mainly dispels pathogens.

Further Clarification 1.About the combination of chái hú and huáng qín

The foot shaoyang channel passes through the chest and covers the ribside. It is located between the taiyang (exterior) and yangming (interior). When cold damage invades the shaoyang, which belongs to half-exterior half-interior, there will be a dysfunction of the pivot and gallbladder-heat harasses the interior. The treatment is to vent the pathogen, clear heat, and soothe and free the qi. Chái hú enters the liver and gallbladder channels, vents the pathogen from the half-exterior and soothes the qi constrained in the shaoyang. Huáng qín also enters the liver and gallbladder channels, clears the half-interior gallbladder-heat in the shaoyang. Chái hú focuses on the half-exterior pathogen and huáng qín focuses on half-interior heat. These two medicinals can regulate and free the movement of qi, simultaneously vent and clear the pathogen, and constitute the basic combination that harmonizes the shaoyang. 2.About the preparation: Why it is necessary to “remove the dregs and boil the decoction again” when preparing Xiăo Chái Hú Tāng? Xiăo Chái Hú Tāng is the representative formula for harmonizing the shaoyang. The medicinals in the formula embody the principle of dualdirection regulation. For example, it uses both cold and warm medicinals simultaneously (the nature of chái hú and huáng qín are cold, while the nature of shēng jiāng, bàn xià, rén shēn, dà zăo, and zhì gān căo are warm). It treats the half-exterior and half-interior simultaneously (chái hú and shēng jiāng vent the half-exterior pathogen, while huáng qín clears half-interior heat). It treats deficiency and excess simultaneously (chái hú, huáng qín, shēng jiāng, and bàn xià vent pathogens, and clear heat to expel pathogens. Rén shēn, dà zăo, and zhì gān căo boost qi and reinforce zheng qi). “Remove the dregs and boil the decoction again” may be an effort to harmonize the nature of all the medicinals in order to harmonize the gallbladder and stomach, as well as to harmonize the contention between the pathogen and

zheng qi. Zhang Zhongjing originally created this method of preparation. In addition to Xiăo Chái Hú Tāng, his other formulas that harmonize the shaoyang and formulas that regulate the stomach and intestines such as Dà Chái Hú Tāng, Bàn Xià Xiè Xīn Tāng, Shēng Jiāng Xiè Xīn Tāng, and Gān Căo Xiè Xīn Tāng are prepared by this method.

Formula Applications 1. Essential pattern differentiation Xiăo Chái Hú Tāng is not only the fundamental formula for treating shaoyang syndrome, it is also a representative formula for harmonizing shaoyang. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of cold damage located in the shaoyang as well as disharmony of the liver and stomach: cold, influenza, malaria, chronic hepatitis, cirrhosis, acute and chronic cholecystitis, gallstones, acute pancreatitis, pleurisy, otitis media, puerperal fever, acute mastitis, orchitis, and bile reflux gastritis. 4. Cautions and contraindications In this formula, chái hú has an ascending and dissipating action, while huáng qín and bàn xià have a drying action. Therefore, it should not be prescribed to treat patients who are yin or blood deficient.

Associated Formulas Chái Hú Guì Zhī Tāng (Bupleurum and Cinnamon Twig Decoction, 柴胡桂枝汤)

[Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct these medicinals with 7 sheng of water, boil them until 3 sheng of water remains, remove the dregs. Take 1 sheng of the warm decoction. [Actions] Harmonizes shaoyang and vents pathogens from the exterior. [Applicable Patterns] Combined taiyang and shaoyang patterns. Symptoms include: externally-contracted wind cold, fever accompanied with spontaneous sweating, slight aversion to cold or alternating chills and fever, nasal congestion, slight vomiting, headache, stiff neck and back, pain and fullness in the chest and rib-side, obstructive sensation in the epigastrium, and a wiry or floating, big pulse. Chái Hú Guì Zhī Tāng is composed of half Xiăo Chái Hú Tāng and half Guì Zhī Tāng. It is indicated for a combination of taiyang and shaoyang patterns characterized by fever, slight aversion to cold, body pain, pain and fullness in the chest and rib-side, and slight vomiting. The fever, slight aversion to cold, and body pain indicate the taiyang pattern. The slight vomiting and obstructive sensation in the epigastrium indicate the shaoyang pattern. Because there are symptoms of both patterns, the combination of

Xiăo Chái Hú Tāng and Guì Zhī Tāng is used to expel the pathogen from the shaoyang through the taiyang.

Case Studies 1. Fever An adult female had taken medication for a common cold and fever two months ago. She returned to work once the fever was gone. In the following two or three days her fever returned. This time she had more symptoms develop along with the fever, and she failed to respond to any medical treatment. Her symptoms included distention and fullness in the chest and rib-side, blockage and oppression in the stomach cavity, poor appetite, a bitter taste in the mouth, tinnitus, afternoon fever, occasional nausea, normal urination and defecation, and normal menstruation. She had a thin white tongue coating. Her right pulse was wiry, slippery and her left pulse was wiry. The Western medicine diagnosis was idiopathic fever. The treatment was to harmonize the shaoyang. So a modified Xiăo Chái Hú Tāng was prescribed composed of chái hú 12 g, huáng qín 10 g, shēng jiāng 3 pieces, zhì gān căo 9 g, zhĭ qiào 10 g, zhĭ shí 10 g, guā lóu 30 g, huáng lián 5 g, and jié gĕng 6 g and prepared as a decoction. After ingesting five dosages of the formula, all her symptoms were mostly alleviated. Four dosages of the same prescription, modified by removing zhĭ shí and adding chén pí 10 g, mài yá 10 g, and dào yá 10 g, was prescribed. She recovered after taking the formula.1 1 Jiao Shu-de. Ten Lectures of Experience Gained in Formulas ⽅剂⼼得⼗讲. Beijing: People’s Medical Publishing House; 1995. p. 57.

Comments: Fever, distention and fullness in the chest and rib-side, poor appetite, a bitter taste in the mouth, tinnitus, nausea, a thin white coating, and a wiry pulse are all symptoms that occur when pathogenic cold enters

the shaoyang. Because of the obvious gallbladder heat and qi stagnation, the supplementing and boosting medicinals were removed and qi-rectifying and heat-clearing medicinals such as zhĭ qiào, guā lóu, huáng lián, and jié gĕng were added. By her second visit, all of the symptoms were mostly alleviated. Four dosages of the same prescription, modified by removing zhĭ shí and adding chén pí 10 g, mài yá 10 g, and dào yá 10 g, was prescribed. She recovered after taking the four dosages of medication. The purpose of using chén pí, mài yá, and dào yá were to strengthen the formula’s ability to harmonize the stomach and activate the spleen. 2. Tuberculosis of the neck Mrs. Meng, a 64-year-old retired worker had her first visit on August 10th, 1987. Her chief complaint was tuberculosis on the right side of the neck as big as a two-cent-coin, which had been there for half of a month. Her left guān pulse was wiry and her tongue coating was yellow and greasy. Her condition was differentiated as constrained shaoyang qi and congealed phlegm-fire. Xiăo Chái Hú Tāng was modified to clear shaoyang, dissolve phlegm, and dissipate constraint. The prescription was composed of chái hú 5 g, huáng qín 6 g, bàn xià (processed) 9 g, tiān huā fĕn 12 g, niú bàng zĭ 12 g, zhè bèi mŭ 12 g, mŭ lì 30 g, chì sháo 9 g, mŭ dān pí 9 g, lián qiào 9 g, xià kū căo 15 g, and qīng pí 6 g. The tuberculosis on her neck disappeared after she took fourteen dosages of the formula. The patient came to express her thanks on September 30th.1 Comments: The tuberculosis was located on the right side of her neck, an area coursed by the shaoyang channel. The wiry left guān and yellow greasy tongue coating are signs of shaoyang qi constraint and congealed phlegm. Since this is an excess heat pattern, rén shēn, zhì gān căo, dà zăo, and shēng jiāng were removed from Xiăo Chái Hú Tāng; and medicinals that

dissolve phlegm and dissipate masses were added. Although the formula was composed of ordinary medicinals, it was able to clear the tuberculosis. Its efficacy was because the formula completely matched the pathology. This case points out that a clear differentiation of the organs and channels involved in the pathology are a key point of diagnosis and treatment.

Dà Chái Hú Tāng ⼤柴胡汤Major Bupleurum Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

1 He Ren, Zhang Zhi-min, Lian Jian-wei. Comments on Medical Cases for Using Formulas of Essentials from the Golden Cabinet⾦匮⽅百家医案评议. Hangzhou: Zhejiang Science and Technology Press; 1991. p. 307.

Preparation and Administration Decoct all 8 medicinals with 1 dou and 2 sheng of water, boil them until 6 sheng of water is left, remove the dregs and bring the decoction to a boil one more time. Take 1 sheng of the warm decoction three times a day. (Modern use: prepare as a decoction.)

Formula Indications

This formula treats a combined shaoyang-yangming pattern characterized by alternating chills and fever, fullness and discomfort in the chest and rib-side, frequent vomiting, constant vexation, epigastric pĭ and hardness or epigastric fullness and pain, constipation or diarrhea with fever, a yellow tongue coating, and a powerful wiry, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis Although this formula treats a combination of shaoyang and yangming patterns, it has its primary focus on addressing the shaoyang. The alternating chills and fever and fullness and discomfort in the chest are symptoms that stem from the pathogen that is remaining in the shaoyang. The frequent vomiting and continuous vexation are worse than those found in the Xiăo Chái Hú Tāng pattern. These symptoms in combination with epigastric pĭ and hardness or epigastric fullness and pain, constipation or diarrhea with fever, the yellow tongue coating, and the powerful wiry, rapid pulse allow us to conclude that the pathogen has entered the yangming and transformed into excess. The purgative method is prohibited in a shaoyang pattern. However, because it is combined with the yangming bowel pattern, the exterior and interior needs to be treated simultaneously. The treatment is to harmonize shaoyang and drain the heat bind from the interior.

Formula Actions Harmonizes shaoyang and drains interior heat bind.

Formula Analysis

Unique Combination Features This formula contains both the harmonizing and purgative methods, but it primarily harmonizes the shaoyang.

Formula Applications 1. Essential pattern differentiation Dà Chái Hú Tāng serves as the most common formula used to treat a combined shaoyangyangming pattern. This clinical pattern is marked by:

2. Modifications

3. Modern Applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a combined shaoyang-yangming pattern: acute pancreatitis, acute cholecystitis, cholelithiasis, gastric and duodenal ulcers due to deficiency-cold of middle jiao, and disharmony of the liver and spleen.

Comparison & Contrast Xiăo Chái Hú Tāng vs. Dà Chái Hú Tāng

Continued

Case Studies Cholecystitis Miss Li suffered from cholecystitis, marked by spontaneous pain and tenderness in the right rib-side, slight fever, accompanied with nausea, poor appetite, abdominal swelling and fullness, enterostomy, belching, and a big, wiry pulse. A modified Dà Chái Hú Tāng was prescribed composed of chái hú 12 g, bái sháo 9 g, zhĭ shí 6 g, dà huáng 6 g, huáng qín 9 g, bàn xià 9 g, shēng jiāng 15 g, dà zăo 4 pieces, jīn qián căo 24 g, huá shí 12 g, and jī nèi jīn 12 g. Her appetite improved and the enterostomy and belching reduced after seven dosages of the formula. After taking another four dosages, the pain in the rib-side was relieved, but the fever remained. Therefore, Xiăo Chái Hú Tāng with the addition of biē jiă, qīng hāo, qín jiāo, and yù jīn was applied.1 Comments: Cholecystitis is marked by spontaneous pain and tenderness in the right rib-side, accompanied with slight fever, nausea, poor appetite, abdominal swelling and fullness, enterostomy, belching, and a big, wiry pulse. These are symptoms of cold damage entering the shaoyang, disturbance of qi movement, and inhibited bowel qi. Dà Chái Hú Tāng was used to harmonize the shaoyang and unblock the bowels through purgation. Jīn qián căo was added to promote the gallbladder function and clear heat. Huá shí was used to promote urination and discharge heat. Jī nèi jīn was used to remove the accumulation and harmonize the stomach. The qi of the bowels was unblocked and the pain in the rib-side was relieved with the

exception of the fever that remained after taking eleven dosages. Xiăo Chái Hú Tāng with the addition of biē jiă, qīng hāo, qín jiāo, and yù jīn are used to clear and vent pathogenic-heat, move qi, and invigorate blood.

Hāo Qín Qīng Dăn Tāng 蒿芩清胆汤Sweet Wormwood and Scutellaria Gallbladder-Clearing Decoction Source Text Revised Popular Guide to ‘Treatise on Cold Damage’ (Chóng Dìng Tōng Sú Shāng Hán Lùn, 重订通俗伤寒论)

Formula Ingredients

1 China Academy of Traditional Chinese Medicine. Case Records of Yue Mei-zhong 岳美中医案 集. Beijing: The People’s Medical Publishing House; 1978. p. 52.

Preparation and Administration Prepare as a decoction.

Formula Indications

Pattern of shaoyang damp-heat marked by alternating chills and fever similar to malaria, more fever than chills, a bitter taste in the mouth, diaphragm oppression, sour and bitter regurgitation, spitting yellow sticky drool, belching, hiccups, distending pain in the chest and rib-side, yellow scanty urine, a red tongue body, a white greasy or white yellow tongue coating, and a rapid, slippery right pulse and a rapid, wiry left pulse.

Analysis of Fundamental Pattern Pathogenesis Hāo Qín Qīng Dăn Tāng is indicated for gallbladder heat, damp-heat, and obstructive turbidphlegm in the shaoyang. Dampness and heat constraint obstructs the shaoyang gallbladder and the shaoyang sanjiao causing blazing ministerial fire of the gallbladder rendering it unable to pivot. Since the constrained heat in the gallbladder channel is more prominent, the alternating chills and fever similar to malaria actually manifest more fever than chills, and is accompanied with a bitter taste in the mouth, diaphragm oppression, and distending pain in the chest and ribside. When gallbladder heat and liver qi invade the stomach, constrained fluid transforms into phlegm, and ascending counterflow of the stomach qi may result, which brings about sour and bitter regurgitation. There may also be spitting yellow sticky drool, belching, or hiccups. When dampness obstructs the sanjiao, the waterways may be inhibited. This is marked by scanty yellow urine. The treatment is to clear the gallbladder, drain dampness, harmonize the stomach, and dissolve phlegm.

Formula Actions Clears gallbladder, drains dampness, harmonizes the stomach, and dissolves phlegm.

Formula Analysis

Continued

Unique Combination Features This formula clears gallbladder heat, dissolves phlegm-damp, frees the qi movement, and harmonizes the stomach qi in order to eliminate all the symptoms related to the pattern.

Formula Applications 1. Essential pattern differentiation

Hāo Qín Qīng Dăn Tāng is the common formula prescribed to treat the pattern of shaoyang damp-heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of dampness and heat constraint obstructing the shaoyang gallbladder and the shaoyang sanjiao: typhoid fever, acute cholecystitis, acute jaundice hepatitis, bile reflux gastritis, pyelonephritis, malaria, pelvic inflammatory disease, and leptospirosis.

Comparison & Contrast Xiăo Chái Hú Tāng vs. Hāo Qín Qīng Dăn Tāng

Case Studies Fever Mr. Zhong, a 52-year-old male, had his first visit on March 26th, 2005. His chief complaint was fever for four days. Four days ago, he developed a fever. Initially he had chills at 5-6 pm, which was followed by a fever from 7-8 pm. His temperature may have even reached 39°C. This morning

however, he had nausea, a bitter taste in the mouth, dry throat, constipation for three days, redness at the margin of the tip of the tongue, a yellow and slight thick tongue coating, and a deep pulse. The pattern differentiation was heat constrained in the shaoyang and phlegmdamp invading the stomach. The treatment was to clear and drain the heat from the shaoyang, harmonize the stomach, and remove dampness. Therefore, a modified Hāo Qín Qīng Dăn Tāng was prescribed, composed of chái hú 18 g, qīng hāo 15 g, huáng qín 15 g, fă bàn xià 15 g, fú líng 15 g, chén pí 12 g, zhú rú 15 g, zhĭ shí 15 g, qīng dài (wrapped) 15 g, huá shí 15 g, pú gōng yīng 25 g, and gān căo 3 g. The second visit was on March 30th. He said that his high fever reduced and his bowels moved once he finishing the second dosage. After taking the third dose, his fever was gone and his appetite improved. The remaining symptoms were soft feet, lack of strength, a bland taste in the mouth, a thick greasy yellow tongue coating, and a deep pulse. The pattern was differentiated as residual dampness. The treatment was to remove dampness using light and aromatic medicinals. Xue Shengbai’s Wŭ Yè Lú Gēn Tāng (Five leaves Reed Yhizome Decoction, 五叶芦根汤) was prescribed composed of bò he 10 g, hé yè 15 g, huò xiāng 15 g, pèi lán 15 g, zhì pí pá yè 15 g, lú gēn 18 g, cāng zhú 15 g, and zhú yè 15 g. The disease was then cured.1 Comments: The fever starting after the chills and was accompanied by a bitter taste in the mouth, which is a sign of heat constraint in the shaoyang. Nausea and a thick slightly yellow coating indicate phlegm-heat invading the stomach and its inability to harmonize and down-bear. Hāo Qín Qīng Dăn Tāng is the best formula to match the pattern pathogenesis. In this case, chái hú, pú gōng yīng, qīng hāo, huáng qín, and qīng dài were added to strengthen the formula to harmonize and eliminate fever. At the second visit,

Xue Sheng-bai’s Wŭ Yè Lú Gēn Tāng was successfully applied in order to treat residual dampness by using light and aromatic medicinals.

Section 2 Formulas that Regulate and Harmonize the Liver and Spleen Formulas that regulate and harmonize the liver and spleen are used to treat disharmony between the liver and spleen, characterized by distending pain of the stomach cavity, abdomen, chest and ribside, mental fatigue, reduced food intake, menstrual irregularities, abdominal pain, diarrhea, and a lack of warmth in the extremities. This pattern is primarily caused by binding constraint of liver qi invading the spleen, or by spleen deficiency with insufficient ying-blood, which causes the liver to be unable to free the qi. Medicinals that soothe the liver and regulate qi such as chái hú, zhĭ qiào, and chén pí are usually used with medicinals that fortify the spleen such as bái zhú, fú líng, and gān căo. Common formulas in this category are Sì Nì Săn, Xiāo Yáo Săn, and Tòng Xiè Yào Fāng.

Sì Nì Săn 四逆散Frigid Extremities Powder Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

1 Feng Quan-sheng. Restricted View of Prof. Zhang Zhi-wen’s Idea of Diagnosis and Treatment of Fever张之⽂教授辨治发热思路管窥. Journal of Sichuan Traditional Medicine. 2005; 23(12): 4.

Preparation and Administration Grind all of the medicinals into powder and mix them together. Take the powder with rice gruel three times a day. (Modern use: prepare as a decoction.)

Formula Indications 1.Pattern of yang constraint and reversal counterflow cold of the limbs, marked by a lack of warmth in the extremities, abdominal pain, diarrhea, dysentery tenesmus, and a wiry pulse. 2.Pattern of disharmony of the liver and spleen, marked by distention and fullness in the ribside, pain in the stomach cavity and abdomen, and a wiry pulse.

Analysis of Fundamental Pattern Pathogenesis Originally Sì Nì Săn is used to treat “counterflow cold of the four limbs in a shaoyin pattern”. Counterflow cold of the four limbs here actually refers to a lack of warmth in the extremities. When an exterior pathogen invades the internal body via the channels, constraint and stagnation of the qi movement occurs. Disordered qi flow causes yang qi constraint, which results in a lack of warmth in the extremities. Later doctors broadened its scope by using it for distention and fullness in the rib-side, and pain in the stomach cavity and abdomen due to liver and spleen constraint and stagnation. The treatment is to move qi, resolve constraint, soothe the liver, and rectify the spleen.

Formula Actions Moves qi, resolves constraint, soothes the liver, and rectifies the spleen.

Formula Analysis

Unique Combination Features This formula treats the liver and spleen simultaneously, but primarily it soothes the liver. It uses the ascending and descending methods together, which treats the qi and the blood at the same time.

Further Clarification About the combination of chái hú and sháo yào Chái hú and bái sháo are commonly used to regulate the liver. The liver is yin in form but yang in function. The ability to free the flow of qi depends on the level of moisture and nourishment of the yin-blood. On the other hand, liver qi constraint and stagnation is easy to develop heat, which may

scorch and damage yin-blood. When internal heat develops due to the consumption and damage of the yin-blood, it may worsen the liver constraint, resulting in nasal dryness and damaged yin-blood. This cycle of pathogenesis forms a vicious circle. Therefore, in order to treat the liver constraint, qi-moving and liver-soothing medicinals are applied in combination with blood-supplementing medicinals. Chái hú is particularly good to promote qi movement by soothing and freeing the liver qi, while bái sháo takes care of the yin-blood of the liver by nourishing the blood and softening the liver. These two medicinals form the basic combination that regulates the liver by addressing the liver through its character of being yin in form but yang in function.

Formula Applications 1. Essential pattern differentiation Sì Nì Săn treats the patterns of yang constraint and reversal counterflow cold of the limbs, which is its original indication. However, later doctors use it as a basic formula to soothe the liver and rectify the spleen. This clinical pattern is marked by:

● a lack of warmth in the extremities ● pain in the rib-side, stomach cavity, and abdomen ● wiry pulse 2. Modifications

3. Modern Applications This formula may be used in the following biomedically defined disorders when the patient shows signs of qi constraint of liver and gallbladder, liver-spleen disharmony, or liver-stomach disharmony: chronic hepatitis, cholecystitis, cholelithiasis, biliary ascariasis, intercostal neuralgia, ulcers, gastritis, gastrointestinal neurosis, annex inflammation, tubal obstruction, and acute mastitis.

Xiāo Yáo Săn 逍遥散Free Wanderer Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind these six medicinals into a crude powder. Take 2 qian (6 g) of the powder and boil it with a big zhan (large bowl) of water, add 1 piece of sliced wēi jiāng, a little bit of bò he and boil down until 7 fen remain, remove the dregs and take the hot decoction any time. (Modern use: Grind these six medicinals into a crude powder and boil 6-9 g with a little wēi jiāng and bò he. Take the draft warm three times a day. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios. )

Formula Indications Xiāo Yáo Săn is indicated for the pattern of liver constraint, blood deficiency, and spleen weakness, characterized by rib-side pain, headache,

dizzy vision, dry mouth, dry throat, mental fatigue, reduced food intake, menstrual irregularities, distending pain of the breasts, and a wiry, deficient pulse.

Analysis of Fundamental Pattern Pathogenesis The liver likes to govern free activity and dislikes inhibition and constraint. It stores the blood and belongs to yin in form but yang in function. When emotion is inhibited, the liver fails to free and soften the form, which may result in liver constraint and blood deficiency. Since “the foot jueyin liver channel distributes along the rib-side, circulates behind the throat… connects with the eyes, ascends to the forehead, and joins the du mai at the top of the head”, liver constraint and blood deficiency may result in rib-side pain, headache, and dizzy vision. When the liver constraint transforms into fire, a dry mouth and dry throat may result. Liver disease tends to transmit to the spleen, which may result in mental fatigue and reduced food intake due to the spleen and stomach weakness. The liver stores the blood and governs the free flow of qi. When women suffer from liver constraint, blood deficiency, and spleen weakness they may suffer menstrual irregularities and distending pain of the breasts. The treatment is to soothe the liver, resolve constraint, nourish blood, and fortify the spleen.

Formula Actions Soothes the liver and resolves constraint, nourishes blood and fortifies the spleen.

Formula Analysis

Unique Combination Features This formula treats the liver and spleen simultaneously and primarily soothes the liver and moves qi. It harmonizes the form and function and treats the qi and blood at the same time.

Further Clarification About the dosage of bò he Bò he has many functions, it scatters and dissipates wind-heat, comforts the throat, promotes the eruption of papules, and soothes and frees the liver. The function that bò he exhibits is dependent on the medicinals it is combined with and its dosage. Medium and large dosages of bò he

emphasize its function to scatter and dissipate wind-heat and promote the eruption of papules; while, a large dosage of bò he emphasizes its function to soothe the liver. This formula is aimed at treating the pattern of liver constraint, blood deficiency, and spleen weakness. In this formula, bò he is used with chái hú to soothe and free the liver; therefore, 6 g is appropriate since it should not be too large.

Formula Applications 1. Essential pattern differentiation Xiāo Yáo Săn serves as the most common formula to soothe the liver and nourish the blood, and is also commonly applied for regulating menstruation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver constraint, blood deficiency, and spleen weakness: chronic hepatitis, cirrhosis, gallstones, gastric and duodenal ulcers, chronic gastritis, gastrointestinal neurosis, premenstrual

stress disorder, breast lobular hyperplasia, menopausal syndrome, pelvic inflammatory disease, infertility, and uterine fibroids.

Associated Formulas Jiā Wèi Xiāo Yáo Săn (Supplemented Free Wanderer Powder, 加味逍 遥散) [Source] Summary of Internal Medicine (Nèi Kē Zhāi Yào, 内科摘要) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Nourishes blood and fortifies the spleen, soothes the liver and clears heat. [Applicable Patterns] Liver constraint and blood deficiency, accompanied with internal heat constraint. Symptoms include: late afternoon tidal fever, vexation, agitation, irascibility, spontaneous sweating, night sweat, headache, dry eyes, red cheek, dry mouth, menstrual irregularities, distending pain of the lesser abdomen, difficult and painful urination, a red tongue with thin yellow coating, and a wiry, deficient, and rapid pulse.

Hēi Xiāo Yáo Săn (Black Free Wanderer Powder, ⿊逍遥散) [Source] Six Texts on Essentials from Medicine—Essential Knowledge of Gynecology (Yī Lüè Liù Shū-Nǚ Kē Zhĭ Yào, 医略六书·女科指要) [Ingredients] Xiāo Yáo Săn with the addition of shēng dì or shú dì huáng. [Preparation and Administration] Prepare it as a decoction. [Actions] Soothes the liver and fortifies the spleen, nourishes blood and regulates menstruation. [Applicable Patterns] Liver and spleen blood deficiency. Symptoms include: abdominal pain near menstruation, and a wiry, deficient pulse. Jiā Wèi Xiāo Yáo Săn is composed of Xiāo Yáo Săn with the addition of mŭ dān pí and shān zhī, therefore it is named Dān Zhī Xiāo Yáo Săn or Bā Wèi Xiāo Yáo Săn. When liver constraint and blood deficiency last for a long time, heat and fire will generate. In such a case, Xiāo Yáo Săn is not powerful enough to calm the fire-heat; therefore, mŭ dān pí is added to clear hidden fire from the blood and shān zhī is added to clear liver heat and drain heat downward. Jiā Wèi Xiāo Yáo Săn is commonly applied for menstrual irregularities, profuse menstrual flow, prolonged menstruation, menstrual hematemesis, and epistaxis due to liver constraint and blood deficiency that is generating heat.

Hēi Xiāo Yáo Săn is composed of Xiāo Yáo Săn with the addition of dì huáng. It treats the same pattern that Xiāo Yáo Săn treats but with severe blood deficiency. Shēng dì should be added for patients with blood deficiency and internal heat while shú dì huáng should be added for patients with blood deficiency but without internal heat.

Case Studies 1. Spotting Miss Guo, a 32-year-old female, had red and occasionally pale menstrual spotting for three weeks. It was accompanied with pain in the back and abdomen, normal appetite, normal defecation and urination, red lips, a red tongue tip, a thin tongue coating, a deep pulse with a wiry guān and a faint left chĭ. A deep, wiry pulse in the liver position (guān) often indicates qi constraint. When constrained liver qi transforms into heat, incessant spotting may result since the liver channel transverses the genitals. The color of the spotting would occasionally become pale due to the blood deficiency that was caused by the prolonged menstrual period. The treatment was to soothe the liver, clear heat, boost the spleen, and stanch bleeding. A modified Jiā Wèi Xiāo Yáo Săn was prescribed composed of dāng guī 10 g, bái sháo 10 g, chái hú 10 g, fú líng 10 g, bái zhú (dry-fried) 10 g, páo jiāng tàn 10 g, huáng qín 10 g, zhī zĭ (scorch-fried) 10 g, dì yú tàn 10 g, ài yè tàn 10 g, jīng jiè tàn 12 g, dăng shēn 10 g, huáng qí 12 g, and shēng dì 10 g. On the second visit the pattern did not have any obvious change. The former formula was prescribed but with some modifications. It was composed of dāng guī 10 g, bái sháo 10 g, chái hú 10 g, fú líng 10 g, bái zhú (dry-fried) 10 g, xiāng fù (processed) 10 g, huáng qín 10 g, zhī zĭ (scorchfried) 10 g, dì yú tàn 10 g, ài yè tàn 10 g, lóng gŭ 10 g, and zhì gān căo 3 g.

On the third visit, after medication, the spotting and abdominal pain was eliminated, but there was generalized weakness. The tongue coating was white and the pulse was thin. The former formula was applied again, but with some modifications: dāng guī 10 g, bái sháo 10 g, chái hú 10 g, fú líng 10 g, bái zhú (dry-fried) 10 g, xiāng fù (processed) 10 g, huáng qín 10 g, zhī zĭ (scorch-fried) 10 g, dì yú tàn 12 g, ài yè tàn 10 g, lóng gŭ 10 g, huáng qí 10 g, and zhì gān căo 10 g.1 Comments: Prolonged, slow, scanty uterine bleeding, called spotting, is mainly caused by damage to the chong and ren mai, and their failure to secure and contain the blood. The pathological damage to the chong and ren mai includes blood heat, qi deficiency, qi constraint, and blood stasis. The most common pathologies are blood heat and qi deficiency. 1 Liu Bi-chen. Summarized Dissemination of the Liu Bi-Chen’s Clinical Experience刘弼臣临床 经验辑要. Beijing: China Medico-Pharmaceutical Sciences and Technology Publishing House; 2002. p. 790.

In this case, the menstrual spotting had lasted for three weeks. The color was red and occasionally pale, other symptoms included pain of the back and abdomen, red lips and tongue tip, a thin tongue coating, and a deep pulse with a wiry guān and faint, weak pulse in the left chĭ. The case was differentiated as constrained qi transforming into heat. The treatment was to soothe the liver and clear heat; therefore a modified Jiā Wèi Xiāo Yáo Săn was applied. Huáng qín and shēng dì were used to strengthen the ability to clear the liver and cool the blood. Páo jiāng tàn, dì yú tàn, ài yè tàn, and jīng jiè tàn all are astringent medicinals that stanch bleeding. Dăng shēn and huáng qí boost qi, contain blood, and fortify the spleen to generate and transform ying-blood. The bleeding was stopped after only three dosages. 2. Pain in the rib-side

Mr. Jing, 36 years old, had his first visit on February 12th, 1993. His chief complaint was two years of intermittent pain in the right rib, which had just increased over the last week. He had a twoyear history of chronic cholecystitis. Although both Chinese medicine and Western medicine treatments were used, his condition would occasionally alleviate and occasionally become aggravated. The pain would become aggravated due to inhibited emotions or an improper diet. One week ago, the disease relapsed because he had an excessive amount of food and wine. A B-ultrasound showed that the gallbladder wall had become rough and thickened. The diagnosis was an acute attack of chronic cholecystitis. The symptoms and signs were scurrying pain in the stomach cavity and rib-side, dizzy vision, irritable mood, vexation and agitation, dry mouth, a bitter taste in the mouth, insomnia, profuse dreaming, poor appetite and digestion, abdominal distention, belching, sallow yellow complexion, emaciation, dry stool, a red enlarged tongue with a thin yellow coating, and a wiry, thready, and rapid pulse. The Chinese medicine diagnosis was pain in the rib-side due to spleen deficiency and liver constraint. The treatment was to fortify the spleen and harmonize the stomach, soothe the liver, regulate qi, and clear heat. A modified Jiā Wèi Xiāo Yáo Săn was prescribed composed of dāng guī 12 g, bái sháo 15 g, bái zhú 10 g, fú líng 15 g, chái hú 5 g, yù jīn 10 g, yán hú suŏ 10 g, chuān liàn zĭ 12 g, mŭ dān pí 6 g, zhī zĭ 10 g, shā rén 8 g, hòu pò 10 g, zhĭ shí 10 g, and gān căo 3 g. Seven dosages were dispensed and they were to be prepared as a decoction. He was given the advise to relax his emotions, improve his diet, and to stop smoking and drinking. He had his second visit on February 19th, 1993. After taking the prescription, all of his symptoms were alleviated. Zhú rú 10 g and jú huā 10

g were added to the former prescription to strengthen its ability to clear heat. He was given nine dosages to prepare as a decoction. The third visit was on February 28th, 1993. The dizzy vision, dry mouth, bitter taste in the mouth, irritable mood, and vexation and agitation were all eliminated. The defecation normalized at one bowel movement per day, and the pain in the rib-side was greatly reduced. The remaining symptoms and signs were poor appetite, poor sleep, pale-red enlarged tongue with a thin white coating, and a wiry, thready pulse. The elimination of the dizzy vision, dry mouth, bitter taste in the mouth, irritable mood, vexation and agitation, the normal defecation, and the thin white tongue coating all indicated that the liver constraint generating heat had resolved. The heatclearing medicinals such as zhī zĭ, zhú rú, and jú huā were then removed. Xiāng fù 10 g was added to strengthen the ability to soothe the liver and regulate the qi. In order to treat the poor appetite and sleep, mài yá (dry-fried until scorched) 12 g, shān zhā (dry-fried until scorched) 12 g, and shén qū (dry-fried until scorched) 12 g were added to help fortify the spleen, harmonize the stomach, promote digestion, and resolve stagnation. In addition, yè jiāo téng 30 g was added to nourish the heart and calm the mind. Twelve dosages were given to be prepared as a decoction. The fourth visit was on March 12th, 1993. All symptoms were gone and his spirit and appetite were good. He was advised to keep taking Xiāo Yáo Wán (patent drug of Xiāo Yáo Săn) for three months to consolidate the curative effect.1 1 Guo Shu-yun, Li Zheng-sheng. Collected Medical Works and Medical Cases of Li Zhen-hua 李 振华医案医论集. Beijing: People’s Medical Publishing House; 2008. p. 66.

Comments: The pain in the rib-side is due to the liver and gallbladder, and it is also associated with the spleen and stomach. In this case, the prolonged pain in the rib-side caused liver qi constraint. When the wood

failed to soothe the earth, spleen and stomach deficiency was the result. An improper diet worsened the deficient spleen and stomach, which lead to the failure of transportation. Then, congestion of the earth and constraint of the wood caused the deficiency and stagnation to get worse and become recalcitrant. The scurrying pain in the stomach cavity and rib-side was due to the disharmony of the liver and spleen and the liver failing to govern free activity. When liver constraint generates fire and flames upward, dizzy vision, dry mouth, and a bitter taste in the mouth result. When heat harasses the heart spirit, irritable mood, vexation and agitation, and insomnia result. When wood constraint restricts the earth, the spleen fails to transport, and there will become a problem with ascending and descending. The poor appetite and digestion, abdominal distention, and belching are a result of it. Based on the correlation of all four examinations, the case was diagnosed as a pattern of spleen deficiency, liver constraint, and liver constraint transforming into fire. The treatment method used was to soothe the liver and fortify the spleen. A modified Jiā Wèi Xiāo Yáo Săn was prescribed. Since qi flow promotes blood circulation, qi constraint causes blood stasis. Therefore zhĭ shí, yù jīn, yán hú suŏ, and chuān liàn zĭ were added to reinforce the ability to move the qi, invigorate the blood, resolve constraint, and relieve pain.

Tòng Xiè Yào Fāng 痛泻要⽅Important Formula for Painful Diarrhea Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

Preparation and Administration Prepare it as a decoction.

Formula Indications Painful diarrhea due to a deficient spleen and a vigorous liver, characterized by borborygmus, abdominal pain, diarrhea with abdominal pain, pain that is relieved after diarrhea, the guān pulses of both hands are not in harmony, there is a wiry pulse on the left hand, and a moderate pulse on the right.

Analysis of Fundamental Pattern Pathogenesis Painful diarrhea is due to wood over-restricting the earth, liver-spleen disharmony, and the spleen failing to transport. As mentioned in

Investigations of Medical Formulas, “diarrhea is caused by the spleen deficiency while the pain is due to liver excess. A deficient spleen and a vigorous liver may result in painful diarrhea.”[2] The methods of supplementing the spleen and inhibiting the liver, dispelling dampness, and arresting diarrhea are appropriate to use because there is diarrhea and abdominal pain.

Formula Actions Supplements the spleen and softens the liver, dispels dampness and arrests diarrhea.

Formula Analysis

Unique Combination Features This formula simultaneously treats the liver and spleen, but it primarily supplements the spleen. It treats the qi and body fluids together, and mainly dries dampness.

Formula Applications 1. Essential pattern differentiation Tòng Xiè Yào Fāng is a commonly used formula for painful diarrhea due to liver-spleen disharmony. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a deficient spleen and a vigorous liver: acute enteritis, chronic colitis, and irritable bowel syndrome.

Case Studies Diarrhea Mr. Chen suffered from chronic enteritis marked with diarrhea. He had diarrhea four to five times each day preceded with borborygmus and abdominal pain. When he felt the pain he would rush to toilet and release profuse flatulence and unformed stool with foam. His case was diagnosed as diarrhea due to wind. Tòng Xiè Yào Fāng was prescribed to harmonize the

liver and fortify the spleen. It was composed of bái zhú 12 g, sháo yào 9 g, chén pí 6 g, and fáng fēng 3 g. The patient recovered after taking the formula.1 Comments: Diarrhea due to wind means lienteric diarrhea (diarrhea with undigested food) due to intestinal wind. This is a common disease that is easily misdiagnosed as diarrhea due to an accumulation of food or dampness. The hidden wind causes pathogenic qi to linger, resulting in through-flux diarrhea. In the clinical practice many cases of diarrhea due to wind fail to be cured. The case was diagnosed as diarrhea due to wind and Tòng Xiè Yào Fāng was prescribed to soften the liver and fortify the spleen. Thereafter, the patient recovered after taking the formula.

Section 3 Formulas that Regulate the Stomach and Intestines Formulas that regulate the stomach and intestines are used to treat binding of cold and heat in the middle jiao and disorder of the ascending and descending movement of qi. The signs and symptoms include pĭ and fullness below the heart, nausea, vomiting, borborygmus, and diarrhea. Both acridwarm medicinals and bitter-cold medicinals such as gān jiāng, shēng jiāng, bàn xià, huáng lián, and huáng qín are often used in formulas that regulate the stomach and intestines. Bàn Xià Xiè Xīn Tāng is a representative formula from this category.

Bàn Xià Xiè Xīn Tāng 半夏泻⼼汤Pinellia HeartDraining Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) 1 China Academy of Traditional Chinese Medicine. Case Records of Yue Mei-zhong 岳美中医案 集. Beijing: People’s Medical Publishing House; 1978. p. 44.

Formula Ingredients

Preparation and Administration Decoct these seven medicinals with 1 dou of water, boil them until 6 sheng of water remains, remove the dregs, and boil them until 3 sheng of water is left. Take 1 sheng of the warm decoction three times a day. (Modern use: prepare as a decoction.)

Formula Indications Pĭ is caused by the binding of cold and heat, marked by stuffiness below the heart, fullness without pain, vomiting, borborygmus, diarrhea, and a slightly yellow, greasy coating.

Analysis of Fundamental Pattern Pathogenesis The pattern of pĭ treated by Bàn Xià Xiè Xīn Tāng is originally caused by inappropriate purgative treatment in a Xiăo Chái Hú Tāng pattern. The purge damages the yang in the middle jiao and the shaoyang pathogenic heat invades inward. The result is pĭ below the heart because of the binding of cold and heat. Pĭ describes an obstruction, which causes the interaction between the upper jiao and lower jiao to fail. Pĭ below the heart actually

refers to pĭ in the stomach cavity. The spleen and stomach are located in the middle jiao, which is the hub of the ascending and descending movement of qi. Since center qi weakness leads to binding of cold and heat, pĭ may result. The spleen is a yin zang that governs ascent, while the stomach is a yang fu that governs descent. Damaged center qi may cause disordered ascending and descending, which may lead to vomiting, pathogenic ascending, and borborygmus and diarrhea, pathogenic descending. The pathogenesis of this pattern is quiet complicated because the middle jiao disharmony and the disordered ascending and descending are due to the binding of cold and heat, as well as, a deficiency-excess complex. The treatment is to harmonize the cold and warm aspects, boost qi, harmonize the stomach, dissipate masses, and disperse pĭ.

Formula Actions Disperses pĭ and dissipates masses through the combination of cold and warm medicinals.

Formula Analysis

Unique Combination Features This formula has the characteristic features of using cold and warm medicinals to harmonize yin and yang, acrid medicinals that open, and bitter medicinals that promote descent. It also has the ability to simultaneously treat deficiency and excess through the combination of medicinals that supplement and drain.

Further Clarification About acrid medicinals that open and bitter medicinals that promote descent This is a particular type of combination that uses acrid warm medicinals in combination with bitter cold medicinals. This combined method is used to harmonize the cold and warm aspects, diffuse and unblock qi movement, direct qi downward and arrest vomiting, and disperse pĭ and eliminate fullness. It is applicable for binding of cold and heat or damp-heat

accumulation, characterized by pĭ and fullness, diarrhea, and vomiting. In this formula, acrid warm (hot) bàn xià and gān jiāng are used together with bitter cold huáng qín and huáng lián in order to manifest the therapeutic effect of acrid medicinals that open and bitter medicinals that promote descent.

Formula Applications 1. Essential pattern differentiation Bàn Xià Xiè Xīn Tāng is a commonly used formula used to treat the disharmony of the intestinesstomach due to center qi weakness, binding cold and heat, and disordered ascending and descending of the qi movement. It is also a common formula to utilize the method of harmonizing the cold and warm aspects through the combination of cold and warm medicinals. It uses acrid medicinals to open and bitter medicinals to promote descent. This clinical pattern is marked by:

● pĭ and fullness below the heart ● vomiting and diarrhea ● slightly yellow greasy tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of binding cold and heat and center qi deficiency: acute and chronic gastroenteritis, chronic colitis, chronic hepatitis, and early cirrhosis. 4. Cautions and contraindications This formula is not applicable for pĭ and fullness below the heart due to qi stagnation or food accumulation.

Associated Formulas Shēng Jiāng Xiè Xīn Tāng (Fresh Ginger Heart-Draining Decoction, ⽣姜泻⼼汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct these eight medicinals with 1 dou of water, boil them until 6 sheng of water remains, remove the dregs, and boil them again. Take 1 sheng of the warm decoction three times a day. [Actions] Harmonizes the stomach and disperses pĭ.

[Applicable Patterns] Pĭ syndrome due to binding cold and heat. Symptoms include: pĭ and hardness below the heart, belching that smells like food, and diarrhea with thunderous rumbling in the abdomen. Gān Căo Xiè Xīn Tāng (Licorice Heart-Draining Decoction, ⽢草泻⼼ 汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct these seven medicinals with 1 dou of water, boil them until 6 sheng of water remains, remove the dregs, and boil them again. Take 1 sheng of the warm decoction three times a day. [Actions] Harmonizes the stomach, supplements the center, directs counterflow downward, and disperses pĭ. [Applicable Patterns] Pĭ syndrome due to stomach qi deficiency. Symptoms include: diarrhea dozens of times with undigested food in the stool, diarrhea with thunderous rumbling in the abdomen, pĭ, hardness, and fullness below the heart, belching, vexation and easy to get upset.

Shēng Jiāng Xiè Xīn Tāng is composed of Bàn Xià Xiè Xīn Tāng with 2 liang of gān jiāng removed and 4 liang of shēng jiāng added. Using shēng jiāng in a large dosage aims to harmonize the stomach and direct counterflow downward, diffuse and dissipate water, and disperse pĭ and fullness. When combined with acrid medicinals that open and bitter medicinals that promote descent, and medicinals that supplement and boost the spleen and stomach, it treats the pĭ syndrome due to binding water and heat in the middle jiao, and the disorderly ascending and descending of the spleen and stomach qi movement. Gān Căo Xiè Xīn Tāng is composed of Bàn Xià Xiè Xīn Tāng with large amount of zhì gān căo. The large dosage of zhì gān căo aims to harmonize the center and supplement deficiency. When it is combined with acrid medicinals that open and bitter medicinals that promoting descent, it may treat pĭ syndrome caused by stomach qi deficiency, and binding cold and heat.

Case Studies Chronic gastritis Mr. Hu suffered from chronic gastritis. He felt pĭ and fullness below the heart, had belching that smelled like food after eating for years, thunderous rumbling in the abdomen, lusterless complexion, and a lean stature. The pĭ and hardness below the heart was identified as food stagnation generating gas due to a weak stomach. The thunderous rumbling in the abdomen was caused by water retention in the stomach pouring downward into the intestines. All the signs and symptoms refer a Shēng Jiāng Xiè Xīn Tāng pattern. Therefore, Shēng Jiāng Xiè Xīn Tāng was prescribed composed of shēng jiāng 12 g, zhì gān căo 9 g, dăng shēn 9 g, gān jiāng 3 g, huáng qín 9 g, huáng lián 3 g, bàn xià 9 g, and dà zăo 4 pieces. The medicinals were

decocted with eight cups of water and boiled down until four cups of water remained. The dregs were removed and the decoction was boiled again until two cups of water was left. He took the decoction two times a day. After taking the medicine for one week, all of the symptoms were eliminated except for the poor appetite. A modified Jiā Wèi Liù Jūn Zĭ Tāng was prescribed, and his appetite improved.1 Comments: This case belongs to pĭ syndrome that was caused by the binding of water and heat in the middle jiao and disordered ascending and descending of the spleen and stomach qi. Shēng Jiāng Xiè Xīn Tāng was therefore prescribed. After taking the medicine for one week, all of the symptoms were eliminated except for the poor appetite. Poor appetite indicates spleen deficiency failing to transport. A modified Liù Jūn Zĭ Tāng was prescribed to boost qi, fortify the spleen, move qi, and dry dampness.

Summary There are seven formulas within the Formulas that Harmonize chapter. They are categorized as:

● formulas that harmonize the shaoyang ● formulas that regulate and harmonize the liver and spleen ● formulas that regulate the stomach and intestines 1. Formulas that harmonize the shaoyang 1 China Academy of Traditional Chinese Medicine. Case Records of Yue Mei-zhong 岳美中医案 集. Beijing: People’s Medical Publishing House; 1978. p. 43.

Xiăo Chái Hú Tāng is a commonly used formula to harmonize the shaoyang and is indicated for cold damage entering the shaoyang. The symptoms are alternating chills and fever, fullness and discomfort in the

chest and ribside, no desire to eat or drink, vexation, and frequent vomiting. Dà Chái Hú Tāng harmonizes the shaoyang, drains internal heat bind, and treats patterns of combined shaoyang-yangming, characterized by alternating chills and fever, fullness and discomfort in the chest and rib-side, frequent vomiting, epigastric pĭ and hardness, or epigastric fullness and pain, constipation, a yellow tongue coating, and a powerful wiry, rapid pulse. Hāo Qín Qīng Dăn Tāng clears the gallbladder, drains dampness, harmonizes the stomach, and dissolves phlegm. It treats gallbladder heat, damp-heat, and phlegm-turbid obstructing the shaoyang characterized by alternating chills and fever similar to malaria, more fever than chills, a bitter taste in the mouth, diaphragm oppression, sour and bitter regurgitation, and a slightly yellow, greasy coating 2. Formulas that regulate and harmonize the liver and spleen Sì Nì Săn vents pathogens, resolves constraint, soothes the liver, and rectifies the spleen. It is indicated for a lack of warmth in the extremities due to yang qi constraint and for pain in the stomach cavity and abdomen due to a disharmony of the liver and spleen. The pattern of Xiāo Yáo Săn is caused by a pattern of liver constraint, blood deficiency, and spleen deficiency, especially caused by liver constraint and blood deficiency. Xiāo Yáo Săn soothes the liver, resolves constraint, nourishes the blood, and fortifies the spleen. It treats the rib-side pain, headache, dizzy vision, dry mouth, dry throat, mental fatigue, reduced food intake, and menstrual irregularities. Tòng Xiè Yào Fāng supplements the spleen and softens the liver; however, it especially treats the spleen. It is indicated for painful diarrhea caused by spleen deficiency and a vigorous liver. 3. Formulas that regulate the stomach and intestines

Bàn Xià Xiè Xīn Tāng regulates and harmonizes the cold and warm aspects through its combination of cold and warm medicinals. It disperses pĭ and dissipates masses. Bàn Xià Xiè Xīn Tāng is indicated for pĭ, vomiting, and diarrhea caused by center qi weakness, and binding cold and heat in the middle jiao.

Questions 1.Xiăo Chái Hú Tāng and Dà Chái Hú Tāng are both formulas that harmonize the shaoyang. How do these two formulas differ in composition, actions, and indications? 2.State the indications of Hāo Qín Qīng Dăn Tāng. Please state the meaning associating with medicinals. 3. Xiāo Yáo Săn and Tòng Xiè Yào Fāng are both formulas that regulate and harmonize the liver and spleen. State the differences between the combinations of medicinals used in each and how to determine when they should be applied. 4.If Tòng Xiè Yào Fāng is a formula used to treat a deficient spleen and vigorous liver, why does it include fáng fēng, a medicinal that expels wind? 5.Analyze the disease mechanism of Bàn Xià Xiè Xīn Tāng’s indications and the meaning of the combination of its medicinals.

Endnotes: [1] 上焦得通，津液得下，胃⽓因和，身濈然汗出⽽解 [2] 泻责之脾，痛责之肝︔肝责之实，脾责之虚，脾虚肝实，故令 痛泻

CHAPTER 4 Heat-Clearing Formulas The heat-clearing formulas use heat-clearing medicinals as their major components and have the therapeutic actions to clear heat, purge fire, cool blood, and resolve toxins. They are used for treating patterns of internal heat. The heat-clearing therapeutic method was formed according to the theories “treat the heat with cold” [1] and “the warm can be cleared away” [2] described in The Yellow Emperor’s Inner Classic: Basic Questions -Great Treatise on the Essentials of Supreme Truth (Huáng Dì Nèi Jīng Sù Wèn-Zhì Zhēn Yào Dà Lùn, 黄帝内经素问·至真要⼤论). Historically, it has been referred to as the heat-clearing method, which is one of the “eight medicinal treatment methods” recorded in ancient literature. The externally-contracted six pathogenic factors can invade into the internal human body and generate fire. An excess of the five minds makes the zang-fu organs hyperactive and produce fire. Internal injury and chronic disease deplete yin and fluids, which cause deficiency heat to flare. Therefore, patterns of internal heat are generated from both internal and external aspects. The formulas in this chapter are classified as five types according to the location of the heat and the nature of the disease. Heat may be located at the qi level, blood level, or zang-fu organs, and the nature of the heat may be excess heat or deficiency heat. The formulas discussed in this chapter are:

● heat-clearing formulas that clear heat from the qi level ● heat-clearing formulas that clear the ying level and cool blood ● heat-clearing formulas that resolve toxins ● heat-clearing formulas that clear heat from the zang-fu organs ● heat-clearing formulas that clear deficiency heat ● heat-clearing formulas that clear summerheat There are some cautions that should be observed when prescribing heatclearing formulas. First, it is important to differentiate the location of the internal heat. If the heat is in the qi level, but the prescription given is for the blood level, the pathogen may be led to the deeper into the blood level; and if the heat is in the blood level, there will be no effect if the prescription is working at the qi level. Second, differentiate between true or false phenomenon within the heat pattern. If there is true cold with false heat, heat-clearing formulas are prohibited. Third, differentiate whether the pattern is a deficiency or excess heat pattern. If the heat cannot be removed by formulas that clear heat and drain fire, then the method of enriching yin and fluids with medicinals that have a sweet taste and cold property should be applied. After yin is restored, the heat will clear automatically. Forth, evaluate the degree of the heat and select the formula that appropriately matches the pattern. If the heat is excessive but the formula does not clear heat strongly, the fire cannot be extinguished. If the heat is mild but the dosage of heat-clearing formulas is big, the heat may be cleared but the formula will generate internal cold. For the patients who generally have yang deficiency along with spleen and stomach deficiency, even though the externally affected pathogens invade internally and transform into heat, the heat-clearing formulas should be used cautiously. Medicinals that awaken the spleen and harmonize the stomach should be combined to protect the

yang and stomach. Fifth, patients who have an intense fire pathogen may vomit when taking the heat-clearing formulas. In order to prevent the formulas from being vomited, adding warm medicinals in small doses or instructing the patient to drink the formula warm may help.

Section 1 Heat-Clearing Formulas that Clear Heat from the Qi Level Heat-clearing formulas that clear heat from the qi level have the therapeutic effect to clear the heat in the qi level. Heat in the qi level manifests fever without an aversion to cold but with an aversion to heat, a lot of sweating, thirst with a desire to drink cold liquids, a red tongue body with a yellow coating, and a rapid, forceful pulse. An excessive internal heat pattern should be treated by the strong heat-clearing method, which primarily uses pungent, sweet, and extremely cold medicinals such as shí gāo, and cold, bitter, and moistening medicinals such as zhī mŭ to compose the formula. Excessive internal heat tends to damage the fluids and consume qi; therefore, medicinals that nourish yin and generate the production of fluids such as tiān huā fĕn, shí hú, and lú gēn are used together with either heat-clearing medicinals or medicinals that supplement qi such as rén shēn and zhì gān căo. If the pattern occurs with yangming bowel excess, medicinals such as dà huáng and máng xiāo are added to purge heat from the yangming fu. If there is disharmony of the stomach with qi counterflow and nausea, medicinals such as bàn xià and zhú rú are used to harmonize the stomach and direct the counterflow of qi downward. If there is an exterior pathogen causing a high fever but no sweating, medicinals such as jīn yín huā, lián qiào, and bò he are used to clear heat and vent pathogen.s If

excessive heat induces liver wind with spasms, medicinals such as líng yáng jiăo, gōu téng, tiān má, and jú huā are used to cool the liver and extinguish wind. Bái Hŭ Tāng and Zhú Yè Shí Gāo Tāng are representative formulas.

Bái Hŭ Tāng ⽩虎汤White Tiger Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Use 1 dou of water (2000 ml) to decoct the four medicinals. After the rice is cooked, strain out the liquid. Take 1 sheng (200 ml) of the decoction warm, 3 times a day.

Formula Indications The formula is indicated for intense heat in the qi level with high fever, red facial complexion, restlessness and thirst, polydipsia, sweating, aversion to heat, and a surging, big, and forceful pulse.

Analysis of Fundamental Pattern Pathogenesis

Bái Hŭ Tāng is the original formula used to treat yangming channel patterns. In this pattern, externally contracted cold pathogens transform into heat and invade inward into the yangming channel. The invasion of warm pathogens from the wei level to the qi level can also produce this pattern. Intense internal heat produces a fever, without aversion to cold. Stomach heat damages the fluids, which then causes thirst and the desire to drink cold fluids. Internal heat steams fluids externally to produce sweating. The surging, big, and forceful pulse manifest from the intense internal heat. The method of clearing heat and generating fluids is the most appropriate for this pattern of intense heat in the qi level.

Formula Actions Clears heat and generates fluids.

Formula Analysis

Unique Combination Features

The formula contains the combination of acrid and cold medicinals used to clear heat and vent pathogens. It also contains nourishing medicinals that safeguard the middle jiao. They can help clear heat without damaging yin-fluids, and prevent cold and cool medicinals from damaging the center qi.

Further Clarification Which is the chief medicinal of Bái Hŭ Tāng, shí gāo or zhī mŭ? There are two plausible answers that are recognized. Cheng Wu-ji believed that zhī mŭ is the chief medicinal because it has a bitter and cold property. The Yellow Emperor’s Inner Classic said that a prevailing heat pathogen should be treated with bitter and sweet medicinals; the interior heat excess would be dispersed by the bitter medicinals. Exterior heat should be cleared mainly by medicinals with a bitter taste. Ke Qin thought that shí gāo is the chief medicinal because the yangming channel belongs to the stomach, which governs the exterior muscles. Even though the flaring heat does not develop into an excess pattern, medicinals with a bitter taste and cold property cannot treat it. However, shí gāo has an acrid taste, which relieves the heat in the muscle and a cold property, which prevails over the stomach fire. Furthermore, a cold property has the sinking and descending characteristic, while the acrid taste expels exterior pathogens; thereby shí gāo should be the chief as it can treat both the exterior and the interior. While both of these doctrines are reasonable, The Yellow Emperor’s Inner Classic said that dispersing fire with a bitter medicinal refers to an excess fire and a constraint fire, without fluids damage. This means that such heat syndromes should be treated with the clearing and dispersing method, and not only the heat-clearing and yingnourishing method; acrid medicinals are often applied. This pattern is heat excess in the yangming channel, which has

interior heat excess with fluid damage. Therefore, the corresponding treatment should be clearing with dispersing. Zhī mŭ has a bitter taste, cold property, and is moistening. Even though it can clear heat and generate fluids, it is not as powerful as shí gāo to clear the heat. It does not have an acrid taste, and therefore does not fit the pattern and treatment. Shí gāo has an acrid and sweet taste, an extremely cold property, and has a clearing and dispersing function. It is mentioned in the Records of Chinese Medicine with Reference to Western Medicine (Yī Xué Zhōng Zhōng Cān Xī Lù, 医学衷中 参西录) that the cold property of shí gāo is far less than huáng lián, lóng dăn căo, zhī mŭ, and huáng băi. However, it has a more powerful effect to relieve heat than they do. The channel affinity of shí gāo is the lung and stomach channels, which is appropriate for the excessive heat in the qi level of the lung and stomach. Therefore, the chief medicinal should be shí gāo, as Ke Qin thought.

Formula Applications 1. Essential pattern differentiation This formula is fundamental for treating excessive heat in the qi level. This clinical pattern is marked by:

2. Modification

3. Modern applications This formula is also used for acute epidemic and infectious diseases such as encephalitis, epidemic hemorrhagic fever, lobar pneumonia, leptospirosis, epidemic cerebrospinal meningitis, influenza, typhoid, acute dysentery, malaria, measles, and sepsis syndrome which have been differentiated as a pattern of excess heat in the qi level. 4. Cautions and contraindications This formula should not be misused in patterns of fever without sweating and thirst in those whose interior symptoms have not released, patients with a superficial and thin or deep pulse, fever due to blood deficiency with a surging pulse that is deep when pressed deeply, and exuberant yin rebelling yang due to true cold with false heat.

Associated Formulas Bái Hŭ Jiā Rén Shēn Tāng (White Tiger Decoction Plus Ginseng, ⽩ 虎加⼈参汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients] Bái Hŭ Tāng with the addition of rén shēn 3 liang (18 g).

[Preparation and Administration] Use 1 dou of water (2000 ml) to decoct the five medicinals. After the rice is cooked, strain out the liquid. Take 1 sheng (200 ml) of the decoction warm, three times a day. [Actions] Clears heat, boosts qi, and promotes fluid production. [Applicable Patterns] Intense heat in the qi level, and damage of qi and fluids. Bái Hŭ Jiā Guì Zhī Tāng (White Tiger Decoction Plus Cinnamon Twig, ⽩虎加桂枝汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要 略) [Ingredients] Bái Hŭ Tāng with the addition of guì zhī 3 liang (18 g). [Preparation and Administration] Grind the medicinals into powder. One dose is 5 qian (15 g). Add 1.5 zhan of water and decoct it until 80% water remain, remove the dregs and take it warm to induce sweat. [Actions] Clears heat, vents pathogens, unblocks the collaterals, and relieves pain. [Applicable Patterns] Warm malaria or wind-damp-heat bì. Bái Hŭ Jiā Cāng Zhú Tāng (White Tiger Decoction Plus Atractylodes, ⽩虎加苍术汤) [Source] Book to Safeguard Life Arranged by Categorized Patterns (Lèi Zhèng Huó Rén Shū, 类证活⼈书) [Ingredients] Bái Hŭ Tāng with the addition of cāng zhú 3 liang (18 g). [Preparation and Administration] Cut the medicinals into the size of bean. One dose is 5 qian (15 g). Add 1.5 zhan of water and decoct it until

80-90% water remain, remove the dregs and take it warm to induce sweat. [Actions] Clears heat and dries dampness. [Applicable Patterns] Damp warmth disease with a preponderance of heat over dampness. The previous three formulas are all modified from the Bái Hŭ Tāng and all have the function to clear heat from the qi level. Bái Hŭ Jiā Rén Shēn Tāng clears heat, boosts qi, and generates fluids. It is applied for excessive heat in the qi level with both qi and yin damage. Bái Hŭ Jiā Guì Zhī Tāng clears and disperses the heat, and dredges the channels and collaterals for patterns of warm malaria, or bì syndromes such as wind, damp and heat bì. Bái Hŭ Jiā Cāng Zhú Tāng clears heat and dries dampness for patterns of damp-warm disease with prominent heat that manifests as chest pĭ and heavy sensation of the body. The tongue has a yellow, greasy, dry coating. Bái Hŭ Jiā Cāng Zhú Tāng is also applied for wind, damp, heat bì, as well as, joint swelling and inflammation.

Case Studies Fever Wang, a 54-year-old male who suffered with a common cold and fever, visited the inpatient department of the hospital on June 12th, 1971. On the 14th, his temperature rose to 38°C during the treatment. Antipyretic medication was given many times, which dropped his temperature, but it would rise again once the medication wore off. After eight days in the hospital, his temperature was over 38.8°C, so TCM treatment was then applied. At that point his symptoms were thirst, sweating, slight throat pain, a floating, large pulse, and a thin, yellow tongue coating. His pattern was differentiated as a pattern of warm heat immersed into yangming. Even

though there was excessive heat on the exterior and in the interior body, it stayed in the qi level. Therefore, it was unnecessary to give bitter, cold medicinals such as huáng lián and huáng qín but a modified Bái Hŭ Tāng would work: shí gāo 60 g, zhī mŭ 12 g, jīng mĭ 12 g, zhì gān căo 9 g, bái máo gēn (fresh) 30 g, lú gēn (fresh) 30 g, lián qiào 12 g. He was instructed to take the decoction warm after the rice was ready. Two days of the prescription was given, taken in the afternoon and evening, and the temperature descended to 38°C. On the 23rd, another two days of the prescription was given again, and the temperature descended to 37.4°C. On the 24th, the dosage of shí gāo was reduced to 45 g, and a oneday dose was given. On the 25th, after the last dose was given, his temperature was back to normal. The thirst and the coating were gone, he was left with only the continuous sweating. He was then prescribed a modified Jià Qīng Tāng (Light Carriage Driving Decoction) of doctor Wang Meng-ying. Afterwards, formulas that supplement qi and strengthen the spleen were given along with a regulated diet, and the patient recovered in a month.1 Comments: Bái Hŭ Tāng is extremely cold. It clears heat in the qi level with a remarkable effect to reduce fever. However, the dosage of shí gāo should be strictly controlled according to the body constitution of the patient, the degree of the fever, and the history of the case. In this case, the patient had a long history of fever with possible qi deficiency. The first formula focused on clearing heat and promoting fluid production but neglected to treat the qi deficiency, so the sweating continued after the fever was gone. Then a modified formula that boosted qi and astringed fluid in addition to clearing heat and venting the pathogen was given, and then the patient recovered. 1 China Academy of Traditional Chinese Medicine. Collection of Yue Mei-zhong Medical Cases 岳美中医案集. Beijing: People’s Medical Publishing House; 1978. p. 103.

Zhú Yè Shí Gāo Tāng ⽵叶⽯膏汤Lophatherum and Gypsum Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Use 1 dou of water to decoct the seven medicinals down to 6 sheng. Filter then put the jīng mĭ into the decoction. After the rice is cooked, filter and drink 1 sheng warm, three doses a day. (Modern use: use water to decoct the medicinals with the jīng mĭ. After the rice is ready, filter and drink warm.)

Formula Indications Cold damage, warm disease, summerheat disease with residual heat, and damage of both qi and fluid. The signs include body fever, profuse

sweating, chest distress and restlessness, nausea, dry mouth and polydipsia, low spirits and weak breathing, dry throat and lips, poor appetite, cough and choking, insomnia, a red tongue with little coating, and a weak and rapid pulse.

Analysis of Fundamental Pattern Pathogenesis In the late stage of a febrile disease, even though the high fever is eliminated, the residual heat stays in the qi level with fever, profuse sweating, dry mouth, and polydipsia. The heat disturbs the heart spirit, so there appears palpitations, restlessness, and insomnia. The heat damages the qi and yin, so there appears fatigue, shortness of breath, dry throat and lips, a red tongue with little coating, and a rapid and deficient pulse. In the late stage of a febrile disease with stomach qi damage, there is a bland taste in the mouth and a poor appetite. The residual heat disturbs internally to produce counterflow lung and stomach qi, nausea, or cough. The characteristic of the formula and pattern is residual heat staying in the lung and stomach with damage of qi and yin and disharmony of the stomach qi.

Formula Actions Clears heat and generates fluids, boosts qi and harmonizes the stomach.

Formula Analysis

Unique Combination Features The combination of the heat-clearing method together with qi-boosting and yin-nourishing methods simultaneously reinforces healthy qi and dispels pathogens. This combined method clears heat but does not freeze, and supplements deficiency but does not create stagnation. Just as the Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) said, “this powerful heatclearing formula is modified into one that is mildly heatclearing and supplementing.” [3]

Formula Applications 1. Essential pattern differentiation

Zhú Yè Shí Gāo Tāng is commonly used for residual heat with both qi and yin consumption, and damage and disharmony of the stomach qi in the later stage of a febrile disease pattern. This clinical pattern is marked by:

2. Modifications

3. Modern applications The formula can be applied for summerheat-strike, febrile disease in the summer, epidemic type B encephalitis, meningococcal meningitis, late period of pneumonia, vomiting after the surgical operation of the biliary tract due to both qi and yin damage and disharmony of the stomach qi with residual heat; as well as the thirst and polydipsia of diabetes due to stomach heat with both qi and yin damage. 4. Cautions and contraindications This formula has a cool property and it functions to clear heat and moisturize. It should not be used for patients with internal phlegm-dampness or fever due to yang deficiency.

Case Studies Pneumonia Qiu, a 10-year-old boy, had his first visit on March 17th, 1981. He had a fever, cough, and shortness of breath for one month following a measles infection. In the hospital he had a chest X-ray radiograph, electrocardiogram, and blood test and was diagnosed with lobar pneumonia and viral myocarditis. He was treated with penicillin, streptomycin, cortisone, and an energy boosting mixture infusion for half a month without any effect. The TCM examination found the he had a fever that was worse in the afternoon (39-40°C), sweating with the fever, restlessness, poor sleep during the night (with occasional screaming), choking cough, shortness of breath, dry mouth with a desire to drink, poor appetite, a thin white and a dry tongue coating, a red tongue, and a rapid, hasty pulse. The differential diagnosis was heat-toxins from the measles invading the heart and lung and there was qi and yin impairment. The treatment was to clear heat and promote fluid production, boost qi and nourish yin. The formula prescribed was a modified Zhú Yè Shí Gāo Tāng composed of zhú yè 15 g, shí gāo 30 g, mài dōng 15 g, fă bàn xià 5 g, bĕi shā shēn 15 g, shí hú (fresh) 15 g, guā lóu pí 10 g, dōng guā zĭ 10 g, and lú gēn (fresh) 3 chi. Three doses of the formula was given. Second visit: March 20th. After the formula was taken for two days, the fever gradually released. On the third day of the treatment the fever was gone, the choking cough was alleviated, and his breathing calmed. His thirst was quenched, his sleep improved, and his screaming stopped. The pulse was still rapid, but not as hasty as it had been. His tongue body was red and had a thin, white, and slightly dry coating. The medicinals tiān huā fĕn 10 g and tài zĭ shēn 15 g were added to the previous formula for another three days.

Third visit: His fever was gone and he was in good spirits. The choking cough gradually stopped as his breathing calmed. His appetite had not yet recovered. His tongue coating was thin, white, and slightly dry and his pulse turned from rapid to moderate. In order to clear and nourish the yin of the lung and stomach, the formula was then changed to Shā Shēn Mài Dōng Tāng.1 Comments: The patient in this case suffered from continuous fever and sweating. His symptoms of restlessness, poor sleep at night with occasional screaming, choking cough, shortness of breath, dry mouth with a desire to drink, poor appetite, and a thin, rapid, hasty pulse were different from the typical yangming channel syndrome. This indicated the pathological involvement of the lung and stomach, and interruption of the ascending and descending of qi, and the damage to both qi and fluids. Zhú Yè Shí Gāo Tāng was effective in this case because it cleared heat, nourished yin, boosted qi, and harmonized the stomach.

Liáng Gé Săn 凉膈散Diaphragm-Cooling Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. One dose is 6 g to 12 g of the powder. Take each dose with zhú yè 3 g and a little honey as a draft. The formula may also be prepared as a decoction for oral ingestion by adjusting the medicinal quantities based on the original ratios.

Formula Indications This formula is indicated for the heat that has been generated from the constraint of pathogens in the upper jiao and middle jiao. The symptoms are vexing heat in the chest and diaphragm, red complexion, parched lips, vexation and agitation, thirst, mouth and tongue sores, restless sleep,

delirium, pharyngeal pain, spitting of blood, nosebleed, constipation, dark urine, and incomplete defecation. The tongue is red with a yellow coating, and the pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis 1 Zhang Rong-chun, Zhang De-chao. Five Cases of Using Classic Formulas 应⽤经⽅治验五则. Chinese Journal of Basic Medicine in Traditional Chinese Medicine. 2000; 6(9): 39-41.

This is a pattern of zang-fu organ heat within the chest and diaphragm, which mainly manifests in the upper jiao and middle jiao. The heat burns in the chest and diaphragm to cause a vexing heat. The heat consumes fluids, which causes thirst, dry throat, and parched lips. Fire flames upward, according to nature, producing a red complexion, red eyes, mouth and tongue sores, pharyngeal pain, spitting of blood, and nosebleed. The heat harasses the heart spirit, causing vexation and agitation, unquiet sleep, or delirium. Dryness-heat binds internally, causing constipation and dark urine. The red tongue with yellow coating, as well as the slippery and rapid pulse, reflects the intense interior heat. The characteristic feature of this pattern’s pathogenesis is the accumulation of zang-fu heat, which rests in the chest and diaphragm, damages the heart and stomach, transforms into fire, and then flames upward.

Formula Actions Drains fire, promotes defecation, clears heat from the upper, and discharges heat through the purgative method.

Formula Analysis

Unique Combination Features This formula primarily clears heat from the upper, and is supplemented by the purgative method. In this formula, the purgative method is a tool for clearing heat in the upper. This is called “purgation as a way of clearing heat” [4].

Formula Applications 1. Essential pattern differentiation Liáng Gé Săn is a commonly used formula applicable for the accumulated heat of the zang-fu organs in the chest and diaphragm. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of accumulated heat in the upper jiao and middle jiao: pharyngitis, stomatitis, acute tonsillitis, infection of biliary tract, cholelithiasis, acute icteric hepatitis, and epidemic cerebrospinal meningitis. 4. Cautions and contraindications Stop taking this formula once constipation is relieved. Otherwise, the spleen and stomach may be damaged. This formula should be taken with caution in pregnant or weak patients.

Case Studies Cheek pain A 55-year-old female had her initial visit in March of 1997. The patient had been suffering from severe paroxysmal pain on her right cheek for six

years. The pain had been worse for ten days before her visit. Since the first onset in 1991, her cheek pain broke out more than ten times a day and would last for ten seconds per episode. The pain felt as though she was being cut with a knife and there was no obvious trigger that induced the painful episodes. The frequency of the episodes increased to a few dozen times per day since ten days prior to the initial visit. She had been diagnosed with trigeminal neuralgia by several hospitals and received treatments from Western medicine, traditional Chinese medicine, and acupuncture. Unfortunately, none of them relieved her pain. On her initial visit, the patient showed a red complexion, thirst, desire for cold drinks, dry bound stool, dark urine, a red tongue body with a rough yellow coating, and a slippery, rapid pulse. The cause of the cheek pain was heat that flared up from the chest and diaphragm, where heat was accumulated. The treatment was to drain fire, promote defecation, clear heat from the upper, and discharge heat by using the purgative method. Liáng Gé Săn was prescribed as a water decoction composed of dà huáng 10 g, zhī zĭ 10 g, huáng qín 10 g, lián qiào 20 g, zhú yè 5 g, gān căo 5 g, pò xiāo 5 g, bò he 5 g, and a little honey. After ingesting one dose of the formula, the constipation and cheek pain were both alleviated. All the symptoms disappeared after another two doses of the formula, with no reoccurrences over the next year.1 1 Han Yi-long. One Successful Case by Using Liáng Gé Săn 凉膈散临证应⽤⼀得. Journal of Practical Traditional Chinese Medicine. 1999; 15 (11): 37.

Comments: The pain was on the right cheek, but the cause was actually an accumulation of heat in the upper jiao and middle jiao. Liáng Gé Săn was able to relieve the cheek pain because it cleared the heat by purging.

Section 2 Heat-Clearing Formulas that Clear Heat from the Ying Level and Cool Blood Heat-clearing formulas that clear the ying level and cool blood are used to treat patterns of heat in the ying level and blood level. They have the therapeutic effect to clear and discharge heat from the ying level, cool blood, and resolve toxins. When there is heat in the ying level, patients have a fever that is aggravated at night, vexation and sleeplessness, occasional delirious speech, inconspicuous macules and papules, and a dry, crimson colored tongue. When there is heat in the blood level, it forces the blood to move frenetically and harasses the heart spirit; which manifests as bleeding, macular eruptions, delirious speech, manic raving, unconsciousness, and a crimson colored, prickly tongue. The formulas are primarily composed of medicinals that clear the ying level and cool blood. For the pattern of heat in the ying level, the treatment is to clear and discharge heat from the ying level by using medicinals to clear the heat and resolve toxins in the ying level as the primary method, and medicinals like jīn yín huā and lián qiào to diffuse and vent pathogenic heat through the qi level as the supplementary method. Qīng Yíng Tāng is a representative formula for this pattern. For the pattern of heat in the blood level, the treatment is to cool blood and dissipate blood stasis, by using medicinals that cool blood and resolve toxins as the primary method, and medicinals like mŭ dān pí and chì sháo to clear the heat, cool blood, invigorate blood, and dissolve stasis as the supplemental method. The purpose is to dissolve stasis and prevent new stasis from forming while

stanching bleeding. Xī Jiăo Dì Huáng Tāng is a representative formula for this pattern.

Qīng Yíng Tāng 清营汤Ying Level Heat-Clearing Decoction Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Use 8 cups of water for each dose of the formula being decocted. Boil the decoction down to 3 cups of water. Take one dose per day divided into three servings. (Modern use: use water to decoct the medicinals.)

Formula Indications

This formula is indicated for heat in the ying level. The symptoms are fever aggravated at night, vexation and sleeplessness, occasional delirious speech, thirst or not, inconspicuous macules and papules, crimson colored, dry tongue, and a thready, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is the initial stage of pathogenic heat entering the ying level. In this stage pathogenic heat enters the ying level and lingers to produce a fever that is aggravated at night. The heat harasses the heart spirit, which causes vexation, sleeplessness, and occasional delirious speech. Once the pathogenic heat enters the ying level, if the heat distills ying-yin upward to the mouth, patients will show no sign of thirst, and if the residual heat in the qi level consumes yin of the lung and stomach, patients will have a fever, thirst, and a dry, crimson colored tongue. The heat burns the blood vessels and forces the blood to flow out of them, which creates inconspicuous macules and papules. The heat consumes ying-yin and leads to the dry, crimson colored tongue and the thready, rapid pulse. The characteristic feature of this pattern pathogenesis is the consumption of yin by the heat in the ying level, and the harassment of the heart and blood vessels by heat.

Formula Actions Clears heat from the ying level, resolves toxins, vents heat from the ying level, and nourishes yin.

Formula Analysis

Unique Combination Features The primary therapeutic method of this formula is to clear heat from the ying level and resolve toxins. Its supplemental method is to nourish ying, promote fluid production, and vent heat from the ying level through the qi level. The aim is to eliminate heat in the ying level by venting the heat through the qi level.

Further Clarification As a formula indicated for heat in the ying level, why are medicinals used for treating disease in the qi level like jīn yín huā, lián qiào, and zhú yè included in Qīng Yíng Tāng? There is no doubt that Qīng Yíng Tāng is indicated for the heat in the ying level, but as the ying level is next to the qi level, there is a chance of venting the pathogenic heat back to the qi level shortly after the heat enters the ying level. Ye Tian-shi, a famous Qing Dynasty expert in warm disease,

said “it is possible to vent heat from the ying level through the qi level after heat has entered the ying level from the qi level”[5]. According to this theory, when treating a pattern of heat in the ying level, extra medicinals, in addition to heat-clearing and yin-nourishing medicinals, should be added to vent heat from the ying level through the qi level. That is why acrid-cool medicinals such as jīn yín huā, lián qiào, and zhú yè are used in this formula to help eliminate the heat in the ying level.

Formula Applications 1. Essential pattern differentiation Qīng Yíng Tāng is a commonly used formula for treating the initial stage of heat entering the ying level. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of heat entering the ying level, or blazing of both qi and ying: epidemic type B encephalitis, epidemic cerebrospinal meningitis, septicemia, typhus abdominalis, and other diseases characterized by fever. 4. Cautions and contraindications Stop taking this formula when patients show symptoms of dampness trapping hidden heat such as a crimson colored tongue with a glossy, white coating. According to the source text of Qīng Yíng Tāng, “do not give the formula to those with a glossy, white tongue coating”[6]. The reason is “a glossy, white tongue coating indicates excessive heat and dampness, and a pattern with excessive dampness should not be treated with yin-nourishing medicinals”[7]. Otherwise the yin-nourishing medicinals may add to the dampness and complicate the illness.

Associated Formulas Qīng Gōng Tāng (Palace-Clearing Decoction, 清宫汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration]

Prepare it as a decoction. [Actions] Clears the heart, resolves toxins, nourishes yin, and promotes fluid production. [Applicable Patterns] Fluid damage due to warm disease and pathogenic invasion into the pericardium. Symptoms include: fever, unconsciousness, and delirious speech. Gōng refers to the pericardium. This pattern is caused by the invasion of warm febrile pathogens into the heart and the ying level, with reversetransmission to the pericardium. As recorded in the source text, the tip of xī jiăo was used, and the cores of other medicinals were included. This is because the core of a medicinal can enter the heart according to the observation of analogy used in traditional Chinese medicine theory. The therapeutic method is to clear the heat of the pericardium, supplement kidney yin, resolve toxins, and dispel filth. The formula clears heat of the heart and at the ying level, coordinates water and fire, resolves toxins, and calms the heart spirit.

Case Studies Convulsion Ma, a three and half-year-old boy, had his initial visit on August 19th, 1963. The patient has had suffered from fever, unconsciousness, and convulsions for five days. Five days prior to the visit, the child developed a fever between 39ºC and 40ºC which remained unchanged even after the application of antibiotics and antipyretics, followed by projectile vomiting,

unconsciousness, and convulsion. A physical examination revealed unconsciousness, neck rigidity, impaired light reaction, negative cremasteric reflex, negative patella tendon reflex, negative abdominal reflex, positive Kernig sign, positive Babinski sign, parched lips, grimy facial complexion, a red tongue body with a thick yellow coating, and a thready, rapid pulse. The pattern of this patient was summerheat entering the ying level, blazing of both qi and ying, clouding of the pericardium, and the internal stirring of liver wind. The therapeutic method was to clear the qi and ying levels, remove turbidity with aromatic medicinals, arouse the spirit, open the orifices, tranquilize the liver, and extinguish wind. The formula prescribed was a modified Qīng Yíng Tāng. The prescription was composed of shí gāo 30 g, zhī mŭ 9 g, shēng dì 15 g, zhī zĭ 9 g, chì sháo 12 g, huáng lián 3 g, xuán shēn 15 g, lián qiào 15 g, shí jué míng 15 g, pèi lán (fresh) 12 g, shí hú (fresh)10 g, and gān căo 6 g. In addition, 1 pill of Zhì Băo Dān (from Beneficial Formulas from the Taiping Imperial Pharmacy) was cut into 6 pieces and taken overnight. Second visit: After ingesting 5 doses of the formula, the temperature of the patient returned to normal, consciousness was regained, convulsions ceased, and his overall condition had improved. However, he still had symptoms of vexation, restlessness, a tender red tongue with a dry yellow coating, and a thready, rapid pulse. The summerheat was cleared, consciousness was regained, and the stirring liver wind was extinguished. The vexation and tender red tongue body with a dry, yellow coating indicated there was residual heat and consumption of yin. The therapeutic method was to clear heat, cool blood, and nourish yin with sweet-cold medicinals. The prescription was composed of shí gāo 20 g, shēng dì 15 g, zhī mŭ 9 g, zhī zĭ 3 g, huáng qín 9 g, xuán shēn 15 g, shā shēn 15 g, lián qiào 9 g, chì sháo 12 g, and huáng lián 3 g. After ingesting 7 doses of the

formula, the patient totally recovered and went back home on September 4th.1 Comments: The disease had a sudden onset as well as rapid transmission and change. The fever and unconsciousness indicated that the pathogen entered the area between the pleura and diaphragm directly. It injured the jueyin liver and shaoyin heart, which caused mutual fanning of wind and fire. The first formula was used to clear the qi level and ying level, remove turbidity with aromatic medicinals, arouse the spirit, open the orifices, tranquilize the liver, and extinguishing wind. As a result, the heat in the ying level was vented through the qi level, where the heat was cleared. Then sweet-cold medicinals were used to nourish yin. This patient who suffered from severe epidemic type B encephalitis was cured with twelve doses of the medicinal formulas, and returned home fifteen days after the initial visit, without any reoccurrence of the symptoms.

Xī Jiăo Dì Huáng Tāng 犀角地黄汤Rhinoceros Horn and Rehmannia Decoction a.k.a. Sháo Yào Dì Huáng Tāng (Peony and Rehmannia Decoction, 芍药地黄汤) Source Text Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘 要)

Formula Ingredients

1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Physician: Zhang Qi’s Medical Cases 中国现代名中医医案精华. Beijing: Beijing Publishing House; 1990.

Preparation and Administration Grind the medicinals into a crude powder. Decoct one dose of the formula with 9 sheng (1800 ml) water, and boil it until the volume shrinks to about 3 sheng (600 ml). Take one dose each day, divided into three equal portions. (Modern use: use water to decoct the medicinals.)

Formula Indications Xī Jiăo Dì Huáng Tāng is indicated for the heat entering the blood level. The manifestations include:

● Symptoms of heat harassing the heart spirit, such as fever, delirious speech, a prickly crimson colored tongue, and a thready, rapid pulse.

● Symptoms of heat burning the blood vessels, such as purpura, spitting of blood, nosebleed, bloody stool, bloody urine, a crimson colored tongue, and a rapid pulse.

● Symptoms of blood amassment and static heat, manic agitation, desire to rinse the mouth with water but no desire to swallow, and sloppy black stool.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of intense heat in the blood level. After heat enters the blood level, it harasses the heart spirit, which causes vexation, clouding, and mania. The heat forces the blood to move frenetically, causing bleeding such as spitting of blood, nosebleed, bloody stool, and bloody urine. In addition, the blood that has been spilt out of the vessels can stay in the body and cause an eruption of macules and blood amassment. Heat in the blood level consumes the fluid composition of the blood, which causes the blood to concentrate and form stasis, which produces a dry crimson colored tongue. Heat binds the blood either within or outside of the vessels causing blood amassment and static heat, which manifests as manic agitation and a crimson colored tongue. Heat forces the moistening blood to descend to the intestines, leading to sloppy black stool. The characteristic feature of this pattern is heat harassing the heart spirit, bleeding, blood amassment, and stasis. In this case, the bleeding will not stop until the heat in the blood level is cleared, and the blood stasis will not be dissolved until the blood is invigorated. Therefore, the therapeutic method is to clear heat, resolve toxins, cool blood, and dissolve stasis. This has been summarized by Ye Tian-shi, a famous expert in warm disease in the Qing Dynasty, as “when

heat enters the blood level, there is the risk of blood consumption and bleeding, which should be treated by cooling and invigorating the blood”[8].

Formula Actions Clears heat, resolves toxins, cools blood, and dissolves stasis.

Formula Analysis

Unique Combination Features This formula cools blood while it invigorates the blood and dissolves stasis. As a result, the heat in the blood level is cleared to stop bleeding, and the blood is invigorated to prevent heat-clearing medicinals from causing the formation of blood stasis.

Formula Applications 1. Essential pattern differentiation Xī Jiăo Dì Huáng Tāng is a commonly used formula used to treat heat entering the blood level in the course of a warm disease. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of intense heat in the blood level: serious hepatitis, hepatic coma, diffuse intravascular coagulation, urinaemia, allergic purpura, acute leukemia, and blood poisoning. 4. Cautions and contraindications Xī Jiăo Dì Huáng Tāng is prohibited to patients with symptoms of yang deficiency, loss of blood, and spleen-stomach weakness as the nature of this formula is cool, heat-clearing, and nourishing.

Associated Formulas Shén Xī Dān (Spirit-Like Rhinoceros Horn Elixir, 神犀丹) [Source] Warp and Woof of Warm-Heat Diseases (Wēn Rè Jīng Wĕi, 温热经纬) [Ingredients]

[Preparation and Administration] Grind the medicinals into fine powder and prepare as pills. Each pill weights 1 qian (3 g). Take 1 pill with water two times a day. [Actions] Clears heat, opens the orifices, cools blood, and resolves toxins. [Applicable Patterns] Summerheat disease, epidemic disease, and pathogens entering the ying level and blood level. Symptoms include: high-grade fever, unconsciousness, delirious speech, purple macules and papules, erosion in the mouth and throat, red eyes, vexation, and a crimson colored tongue. Huà Bān Tāng (Macules Dissolving Decoction, 化斑汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction.

[Actions] Clears heat from the qi level and cools blood. [Applicable Patterns] Blazing of both qi and blood. Symptoms include: eruption of red macules, fever aggravated at night, thirst or no thirst, and a rapid pulse. Both Shén Xī Dān and Huà Bān Tāng clear heat and cool blood. However, they are different in specific ways. Shén Xī Dān is indicated for pathogens entering the ying level and blood level with intense heat toxins. It primarily clears heat, resolves toxins, cools blood, and opens the orifices to regain consciousness. Huà Bān Tāng is indicated for intense heat in the qi level, blood heat, and blazing of both qi and blood. It combines medicinals that clear heat from the qi level and promote fluid production with medicinals that cool blood and resolve toxins. Huà Bān Tāng clears heat from both the qi level and blood level, and drains pathogenic heat to relieve bleeding and macules. That is why the formula is named Huà Bān Tāng “formula for dissolving macules”.

Comparison & Contrast Qīng Yíng Tāng vs. Xī Jiăo Dì Huáng Tāng

Case Studies 1. Nosebleed Ma, a 17-year-old male, suffered from intermittent bleeding from both nostrils for several months. The cause of bleeding was unclear, and the condition did not improve after treatments with Western medicine and traditional Chinese medicine. His condition had become worse over the past two days. He suffered from severe nose bleeding upon mild activity with dark clotted blood, dizzy vision, vexation, a dusky red tongue, and a deep rapid pulse. Zhang Jing-yue in the Ming Dynasty said, “fire is a common cause of bleeding because fire forces the blood to move frenetically; and qi deficiency is a common cause of blood consumption, as deficient qi fails to contain blood.” In this case, the patient suffered from nose bleeding for several months but his tongue was red and his pulse was rapid. There was no sign of deficiency. In addition, the bleeding was severe and rapid, and the blood was dark rather than clear and thin. These are all signs of an excessive heat pattern. Since the nose is the orifice of the lung, the flaming up of lung

heat causes the nosebleed. Since the liver stores blood, the liver qi blazes up and causes dizzy vision. Since the heart governs the blood, heat in the ying level and blood level harasses the heart spirit and causes vexation. Heat burns the vessels and forces the blood to flow out of them, causing the nosebleed with blood clots. In conclusion, this pattern was a nosebleed caused by “flaming up of gallbladder fire and heat in the heart ying”[9] as recorded in Ye Tian-shi’s Case Records as a Guide to Clinical Practice (Lín Zhèng Zhĭ Nán Yī Àn,临证指南医案). The pathogenesis of this pattern is lung heat forcing the blood to move frenetically, damaging the heart and liver, burning the blood vessels, and causing blood stasis. The therapeutic method established by Ye Tian-shi is “treating the intense heat which flares up blood with sweetcold or salty-cold medicinals”[10]. According to this principle, modified Xī Jiăo Dì Huáng Tāng was prescribed as the formula for this patient. The prescription was composed of xī jiăo 6 g (decocted separately and then mixed with the decoction of other medicinals), shēng dì 10 g, chì sháo 10g, mŭ dān pí 10 g, xuán shēn 10 g, mài dōng 10 g, huáng qín 10 g, jú huā 10 g, xiăo jì 15 g, niú xī 15 g, bái máo gēn 15 g, and jiāo shān zhā 15 g, decocted with water. After he ingested three doses of the formula, the nose bleeding stopped and all of the symptoms were alleviated. There were no reoccurrences observed through to the end of the year.1 Comments: In this case, the bleeding was severe and rapid, the blood was thin and dark rather than clear, the tongue was red, and the pulse was rapid. These symptoms were caused by the intense heat, which flared to the lung orifice forcing the blood to flow out of vessels. The formula prescribed was modified Xī Jiăo Dì Huáng Tāng. Xiăo jì and bái máo gēn were added to cool blood, stop bleeding, invigorate the blood, and dissolve stasis. Mài dōng and xuán shēn were added to enrich yin and moisten the lung, and to

protect the blood vessels of the lung from burning. Huáng qín and jú huā were added to clear the heat of gallbladder and liver, and inhibit the counterflow liver qi. Jiāo shān zhā was added as an auxiliary medicinal to invigorate the blood, dissolve stasis, and protect the stomach from the damage of the bitter-cold and salty-cold medicinals. As a result, the formula was modified according to the pathogenesis and achieved a quick effect. 2. Camp fever 1 wang Jing-hong, Li Jun, Zhang Hong-wei. Zhang Xue-wen’s Experience in Medical Treatment 张学⽂医学求索集. Xi’an: Shanxi Science and Technology Press; 1996.

Wang, a 63-year-old male, went to the inpatient department of the hospital on January 26th, 1961, suffering from fever, frequent urination, and lumbar pain. Upon physical examination, widespread red rashes on the limbs and the chest, a red complexion, listlessness, and a fever (38.5°C) were observed. The condition did not improve after the initial treatment, in fact, it worsened two days later. On January 28th the patient was vexed and unconscious, and then was diagnosed with camp fever. The condition did not improve after the treatment of a large dose of alficetin, glucocorticoid, and a blood transfusion. Doctor Mi was asked to give a consultation. At that time, the symptoms were unconsciousness, delirious speech, cracked lips and tongue, bright red rashes all over the body, stiff skin, scant dark urine, constipation for four days, a dry yellow coating, and a large rapid pulse. The pattern was cold damage that transformed into heat that entering the ying level and blood level, and then yang toxins that created rashes. The therapeutic method was to clear heat, resolve toxins, cool blood, and dissolve rashes. The formula prescribed was Xī Jiăo Dì Huáng Tāng combined with Bái Hŭ Tāng. The prescription was composed of xī jiăo 10.5 g (ground into powder and wrapped separately), shí gāo 70 g, zhī mŭ 28 g, jīng mĭ 17.5 g, shēng dì

17.5 g, mŭ dān pí 14 g, and zhì gān căo 10.5 g. On the second visit his consciousness was regained, and his temperature returned to normal. He had a red tongue with yellow coating and a large pulse. The formula prescribed at the second visit was Qīng Wēn Bài Dú Yĭn. The prescription was composed of xī jiăo 10.5 g (ground into powder and wrapped separately), shēng dì 35 g, chì sháo 17.5 g, mŭ dān pí 17.5 g, shí gāo 70 g, zhī mŭ 28 g, jié gĕng 10.5 g, jiāo zhī zĭ 14 g, huáng lián 10.5 g, huáng qín 10.5 g, gān căo 10.5 g, lián qiào 17.5 g, xuán shēn 17.5 g, and zhú yè 10.5 g. After ingesting three doses of the formula, all of his symptoms were relieved. At that point, Zhú Yè Shí Gāo Tāng was prescribed in order to achieve full recovery.1 Comments: This is a case of epidemic rash. There are two patterns of epidemic rash, namely rashes caused by yang toxins and those caused by yin toxins. Since the two patterns are contrary to each other, an accurate pattern differentiation is the key to avoid mistreatment. In this case, the rashes were caused by yang toxins, so the therapeutic method was to clear the pathogenic heat in the qi level and blood level, cool blood, and dissolve rashes. The condition could be worse or fatal if the intense heat transformed into dryness and fire without timely treatment. Doctor Mi first gave the patient Xī Jiăo Dì Huáng Tāng combined with Bái Hŭ Tāng in order to regain his consciousness and normalize his temperature. He then gave three doses of Qīng Wēn Bài Dú Yĭn, and finally Zhú Yè Shí Gāo Tāng to achieve full recovery. The key to his success was the correct pattern differentiation made between yang toxins and yin toxins as the cause of the rash. Xī jiăo could have been replaced by shuĭ niú jiăo at 50 g in this case.

Section 3 Heat-Clearing Formulas that Resolve Toxins 1 Mi Lie-han. Mi Bo-rang’s Case Records ⽶伯让先⽣医案. Beijing: World Book Publishing Company; 1999.

Formulas that clear heat and resolve toxins can be applied to conditions of epidemic warm toxins, fire toxins, sores, and boils. When there is intense heat in the sanjiao, patients show symptoms of vexing heat, disordered speech, spitting of blood, nosebleed, macular eruption, and short voiding of dark urine. As the epidemic heat toxin flames throughout the body to cause blazing of both qi and blood, patients show symptoms of intense heat in qi level such as fever, vexation, and thirst. The heat arouses frenetic movement of hot blood, which causes spitting of blood, nose bleeding, and macular eruptions. There is also symptoms of the heart spirit being harassed by heat such as inconspicuous and delirious speech and symptoms of the head and face being flamed by wind-heat and epidemic toxins such as redness, heat, swelling, and pain in the head and face, sore and swollen throat, and a rough yellow tongue coating. Finally, there are symptoms of intense heat toxins such as abscesses, ulcers, boils, sores, redness, heat, swelling, and pain in the affected area, fear of cold with fever, and a rapid and forceful pulse. The composition of a formula should be decided according to the variable conditions of the patients, such as the intensity of the heat toxin, the location of disease, and any concurrent patterns. Medicinals that drain fire and resolve toxins like huáng qín, huáng lián, lián qiào, jīn yín huā, pú gōng yīng, and dà qīng yè are usually the main medicinals of the composition. For intense heat in the sanjiao, zhī zĭ should be added to drain the heat from the

sanjiao through the urine, and dà huáng should be used in some cases to strengthen the effort to drain fire and resolve toxins, drain heat downward, and relieve constipation. Huáng Lián Jiĕ Dú Tāng is a representative formula for this pattern. For the pattern of epidemic heat toxins flaming through the body with blazing of both qi and blood, shí gāo and zhī mŭ should be added to clear heat from qi level, while shuĭ niú jiăo and shēng dì should be used to clear the ying level and cool blood. The representative formula for this pattern is Qīng Wēn Bài Dú Yĭn. For the pattern of head and face flamed by wind-heat and epidemic toxin, acrid-cool medicinals like bò he, niú bàng zĭ, and jiāng cán should be added to scatter and dissipate the wind-heat. Pŭ Jì Xiāo Dú Yĭn is a representative formula for this pattern. In the initial stage where sores and ulcers are erupting, there is an accumulation of heat toxins, qi stagnation, and blood stasis. For this pattern, qi-regulating, blood-invigorating, mass-dissipating, and pathogen-expelling medicinals should be added to eliminate the sores and ulcers. The representative formula is Xiān Fāng Huó Mìng Yĭn.

Huáng Lián Jiĕ Dú Tāng 黄连解毒汤Coptis ToxinResolving Decoction Source Text (Recorded in) Emergency Formulas to Keep Up One’s Sleeve (Zhŏu Hòu Bèi Jí Fāng, 肘后备急⽅) (Named in) Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘要)

Formula Ingredients

Preparation and Administration Grind the medicinals into crude powder. Decoct 1 dose of the formula with 6 sheng (1200 ml) water, and boil it until the volume shrinks to about 2 sheng (400 ml). Take 1 dose, split into half, twice per day. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for fire toxins in the sanjiao. The symptoms are fever, vexation, delirious speech, sleeplessness, dry mouth and throat, dark urine, spitting of blood, nosebleed, rashes, fever with dysentery, jaundice caused by epidemic toxins, rashes, abscesses, ulcers, boils, a red tongue with yellow coating, and a forceful, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of fire toxins in the sanjiao. The intense fire toxin harasses the mind, which causes fever, vexation, delirious speech, and sleeplessness. Fire consumes fluids, which causes a dry mouth and throat. Fire forces the blood to ascend causing spitting of blood and nose bleeding. Fire burns the vessels and forces the blood to flow out of the vessels into the skin to produce rashes. Fire toxins distress the large intestine to cause a fever with dysentery. Epidemic toxins distress the liver and gallbladder and force the bile to flow to the skin causing jaundice. Fire toxins accumulate in the skin causing abscesses, ulcers, and boils. A red tongue body with a yellow

coating and a forceful rapid pulse are signs of intense fire toxins. The characteristic feature of this pattern’s pathogenesis is rampant fire toxin in the sanjiao. Therefore, the therapeutic method is to clear fire toxins from the sanjiao with bitter-cold medicinals.

Formula Actions Drains fire and resolves toxins.

Formula Analysis

Unique Combination Features This formula directly repulses fire with bitter-cold medicinals, drains fire, and resolves toxins in sanjiao.

Formula Applications 1. Essential pattern differentiation Huáng Lián Jiĕ Dú Tāng is a common formula used for the method of direct repulsion with bitter-cold medicinals, and a fundamental formula for draining fire and resolving toxins. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of fire toxin: blood poisoning, pyemia, acute icteric hepatitis, acute bacillary dysentery, pneumonia, acute urinary tract infection, epidemic cerebrospinal meningitis, epidemic type B encephalitis, and other infectious diseases. 4. Cautions and contraindications Since this formula includes many bitter-cold medicinals, the spleen and stomach can be damaged from long-term use or an overdose of the formula. Do not prescribe this formula for patients who do not have intense fire pathology.

Associated Formulas Xiè Xīn Tāng (Heart-Draining Decoction, 泻⼼汤) [Source]

Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Drains fire and disperses pĭ. [Applicable Patterns] Accumulation of pathogenic heat in the epigastrium and obstruction of qi movement. Symptoms include: soft pĭ and fullness of the epigastrium, vexation, thirst, dark urine, constipation, ungratifying defecation, spitting of blood, nosebleed, a red tongue with a thin yellow coating, and a rapid pulse. Zhī Zĭ Jīn Huā Tāng ( Cape Jasmine Metal Flower Decotion, 栀⼦⾦ 花汤) [Source] Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) [Ingredients] Huáng Lián Jiĕ Dú Tāng with additional dà huáng. [Preparation and Administration] Prepare it as a decoction. [Actions]

Drains fire and resolves toxins. [Applicable Patterns] Huáng Lián Jiĕ Dú Tāng pattern coupled with: constipation, yang type sores, abscesses, and ulcers. Qīng Wēn Bài Dú Yĭn (Epidemic-Clearing Toxin-Resolving Beverage, 清瘟败毒饮) [Source] Achievements in the Treatment of Epidemic Rashes (Yì Zhĕn Yī Dé, 疫 疹⼀得) [Ingredients]

[Preparation and Administration] Decoct shí gāo first. Add the remained medicine and boil them together. [Actions] Clears heat, resolves toxins, cools blood, and drains fire.

[Applicable Patterns] Epidemic heat toxins, and blazing of both qi and blood. Symptoms include: high-grade fever, severe headache, belching, agitation and mania, unconsciousness, delirious speech, eruption of macules, spitting of blood, nosebleed, reversal counterflow cold or convulsion of the limbs, a deep rapid pulse, deep thready rapid pulse, or floating large rapid pulse, dry lips, and a crimson colored tongue. All the above three formulas can drain fire and resolve toxins. However, they have specific differences. In Xiè Xīn Tāng, the chief medicinal dà huáng is used for draining fire, dispersing pĭ, and draining excessive heat in the blood level to relieve bleeding. Dà huáng is used to direct heat downward, and prevent medicinals that stanch bleeding from retaining blood stasis; in this capacity it reflects the method of “using purgation as a way to clear heat” [4]. In Zhī Zĭ Jīn Huā Tāng, dà huáng is added into Huáng Lián Jiĕ Dú Tāng to reinforce its function to drain fire and resolve toxins, and to direct heat downward. As a result, Zhī Zĭ Jīn Huā Tāng is indicated for intense heat toxins with constipation. Qīng Wēn Bài Dú Yĭn is composed of three formulas used in combination with some specific medicinal substitutions. Huáng băi, of Huáng Lián Jiĕ Dú Tāng, is replaced with lián qiào. Jīng mĭ, of Bái Hŭ Tāng, is replaced with zhú yè. Xuán shēn and jié gĕng are added from Xī Jiăo Dì Huáng Tāng. Qīng Wēn Bài Dú Yĭn is a powerful formula with a series of bitter-cold, acrid-cold, and salty-cold medicinals. This formula is indicated for the pattern of epidemic heat toxins and blazing of both qi and blood, the chief medicinal shí gāo powerfully clears heat in yangming channel, and huáng qín, huáng lián, xī jiăo, and shēng dì are used for cooling the blood, resolving toxins, and clearing heat in both qi and blood levels.

Case Studies Blood poisoning and toxic encephalopathy Zhu, a 5-year-old girl, had her initial visit on February 6th, 1980. The patient suffered from a severe burn (total extent of the burn was 27%; 7% wasⅡdegree, and 20% wasⅢdegree) and shock, so she was sent to the inpatient department of the hospital. Her shock was relieved with timely treatment with Western medicine. However, she got blood poisoning through the infected wound, and repeated blood cultures tested positive for staphylococcus aureus and streptococcus hemolyticus. On March 3rd, her temperature suddenly decreased below 37°C, coupled with unconsciousness, convulsions of the limbs, and hypertension. On March 15th, her temperature decreased below 35°C, coupled with dyspnea. She received a tracheotomy and lived with a breathing machine because she could not breathe on her own. The diagnosis was low body temperature due to blood poisoning and toxic encephalopathy. Her condition had not improved with Western medical treatment using antibiotics, symptomatic, and supportive treatment. Doctor Hong was then asked to give a consultation on March 17th, 1980. Upon his examination she was observed to have a low body temperature, reversal counterflow cold of the four limbs, unconscious, hypertension (160/120 mmHg), convulsions of the limbs, opisthotonos, upturned eyes, clenched jaw, breathless, phlegm rale in the throat, scant dark urine (under urethral catheterization), scant dark stool, dark lips, a dark red tongue, unclear coating contaminated by medicine and milk, and a deep thready, rapid pulse. The infection was serious, and the majority of skin flaps grafted failed to survive. The WBC count was 20.4×109/L, NEU was 0.74×109/L, EOS was 0.26 ×109/L, and toxic neutropenia was 0.10×109/L.

The patient’s pattern was internal block by fire toxins, and severe convulsions caused by intense heat. The therapeutic method was used to drain fire, cool blood, resolve toxins, and open the block. The formula prescribed was a modified Huáng Lián Jiĕ Dú Tāng composed of huáng lián 10 g, huáng qín 10 g, zhī zĭ 10 g, dà huáng 10 g (added later), lián qiào 15 g, jīn yín huā 15 g, mŭ dān pí 10 g, zĭ căo 10 g, chì sháo 15 g, shēng dì 15 g, shí chāng pú 15 g, and yù jīn 10 g. (Six doses). Two doses of the formula were given each day, six hours at a time via 100 ml decoction through nasal feeding. In addition, one dose of Ān Gōng Niú Huáng Săn was given to the patient two times a day. By the second visit the frequency of defecation increased up to nine times a day, the volume of dark brown stool was about 100 g for each movement, the daily urine volume increased to over 2000 ml, the temperature increased to 37.4°C, blood pressure was back to normal (100116/60-70 mmHg), convulsions stopped, and the overall condition had improved. The formula was the same as the first visit, but was given one dose a day. On the third visit the symptoms caused by the internal block by the fire toxins had evidently improved, and the temperature and blood pressure remained normal. The patient regained normal breathing and could live without the breathing machine. She was in akinetic autism, with the ability to blink, impaired sense of pain and touch, phlegm rale in the throat, defecation three to five times a day, yellow stool, a red tongue with a thin coating, and a thready, rapid pulse. The WBC count was 8.5×109/L, NEU was 0.74×109/L, and toxic neutropenia count was 0.06×109/L. The therapeutic method at that point was to drain fire, resolve toxins, and eliminate phlegm to open the orifices and regain consciousness. The formula prescribed was modified Huáng Lián Jiĕ Dú Tāng composed of huáng lián 6

g, huáng qín 10g, dà huáng 10 g, shí chāng pú 15 g, yù jīn 15 g, yuăn zhì 6 g, dăn nán xīng 6 g, tiān zhú huáng 10 g, and jiāng cán 10 g. By the fourth visit the patient had taken a dozen doses of the formula, and had both symptomatic and supportive Western medical treatment. She had regained consciousness, normal breathing, temperature, and blood pressure. The results of a blood culture and blood cell count were negative, showing there was no presence of toxic neutropenia. The patient then underwent another skingrafting operation that was successful, and she achieved a full recovery. 1 1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Physician: Zhang Qi’s Medical Cases 中国现代名中医医案精华. Beijing: Beijing Publishing House; 1990.

Comments: This is a case of heat syncope, caused by an internal block by fire toxins. Huáng Lián Jiĕ Dú Tāng was given to drain fire, resolve toxins, cool blood, and open the block. After ingesting the formula, her bowels were unblocked, and the fire toxins could be expelled. As a result, she regained consciousness, the temperature of her limbs and the whole body returned to normal, and the convulsions stopped. The success of this case laid in the consistency between the pattern differentiation and formula selection; although the condition was acute and severe, doctor Hong simply analyzed the pattern differentiation. The keys to cure the patient were finding the cause of the disease, focusing on the essential pattern, analyzing the conditions carefully and patiently, and then giving treatment under the guidance of appropriate theories of traditional Chinese medicine.

Pŭ Jì Xiāo Dú Yĭn 普济消毒饮Universal Relief Toxin-Removing Beverage Source Text Dong-yuan’s Proven Formulas (Dōng Yuán Shì Xiào Fāng, 东垣试效 ⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine powder. Mix one half of the formula dose with water and drink it throughout the day. Mix the other another half of the formula dose with honey to make a pill, and then dissolve the pill in

the mouth before swallowing. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for swollen-head infection (also referred to as massive head scourge). The symptoms are redness, swelling, and pain in the head and face, failure to open the eyes, red, swollen, and sore throat, aversion to co1d with fever, thirst, a red tongue with a yellow coating, and a forceful rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of swollen-head infection, or epidemic swollen-head infection. The cause of the infection is wind-heat and epidemic toxins that have accumulated in the upper jiao and then flame upward to head and face. The wind-heat and epidemic toxins flaming up to the head and face cause the redness, swelling, and pain in the head and face, and the failure to open the eyes. Warm toxins accumulate in the throat to cause a red, swollen, and sore throat. The intense heat consumes fluids and causes thirst. In the early stage the wind-heat attacks the fleshy exterior, and obstructs the wei yang and struggles with the healthy qi to produce an aversion to cold with fever, a red tongue body with a yellow coating, and a forceful rapid pulse. These are all signs of intense interior heat. Epidemic toxins need to be cleared and resolved, the wind-heat needs to be scattered and dissipated, and the disease in the upper part of the body needs to be alleviated. Therefore, the therapeutic method for this pattern is primarily to clear heat and resolve toxins, and secondarily to scatter and dissipate the wind-heat.

Formula Actions

Clears heat, resolves toxins, scatters wind, and disperses swelling.

Formula Analysis

Unique Combination Features This formula, which is particularly indicated for heat toxins affecting the head and face, combines yang-raising and fire-dissipating acrid-cool medicinals with heat-clearing and fire-draining bitter-cold medicinals. It has the effect to “dissipate fire depression”. How are the controversial shēng má, chái hú, huáng qín, and huáng lián used in Pŭ Jì Xiāo Dú Yĭn? Wu Ju-tong of the Qing Dynasty suggested removing shēng má and chái hú from the formula, and removing huáng qín and huáng lián for patients who have had the disease for only one or two days. In his opinion, the swollen-head infection, which is caused by flaming up of wind-heat and epidemic toxins, should not use shēng má and chái hú to raise yang further. Since huáng qín and huáng lián are medicinals indicated for interior

patterns, they should not be used in patients whose middle jiao has not been affected. Wu Ju-tong’s idea has been opposed by other experts. Ye Lin suggested not removing the four medicinals. He felt that at least chái hú and huáng qín should be kept in the formula. In his opinion, since swollen-head infection is caused by the accumulation and obstruction of epidemic warm toxins, “the latent pathogens could not be expelled without using chái hú to open the access of shaoyang”[11]. Therefore, shēng má and huáng lián may be removed from the formula, but chái hú and huáng qín are essential for the formula. According to Supplemental Critical Annotations of the ‘Systematic Differentiation of Warm Diseases’ (Zēng Bŭ Píng Zhù Wēn Bìng Tiáo Biàn, 增补评注温病条辨), Pŭ Jì Xiāo Dú Yĭn combines ascending and descending effects, since shēng má and chái hú are yang-raising and fire-scattering and huáng qín and huáng lián are heat-draining bitter medicinals. In addition, the disease is caused by warm toxins entering the border of the shaoyang channel and yangming channel. The condition will not be improved without using shēng má and chái hú to raise and scatter the pathogen from shaoyang. Chái hú scatters the exterior pathogen, and harmonizes shaoyang when it is coupled with huáng qín. In conclusion, it would be better to keep chái hú and huáng qín in the formula.

Formula Applications 1. Essential pattern differentiation Pŭ Jì Xiāo Dú Yĭn is a commonly used formula used to treat swollenhead infection. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient has symptoms caused by wind-heat and epidemic toxins: facial erysipelas, epidemic parotitis, acute tonsillitis, upper respiratory tract infection, cellularis phlegmasia in the head and face, acute purulent otitis media, acute posteriorganglionitis in the head and face, and adenolymphitis with obstruction of lymphatic return. 4. Cautions and contraindications Since there are many cold-bitter and acrid-dissipating medicinals included in the formula, it needs to be used with caution in patients with long-term yin deficiency, and thin, unformed stool caused by spleen deficiency.

Case Studies Swollen-head infection Zhu had severe swelling in his head and face, coupled with an aversion to cold with fever, thirst, sore throat, and constipation. It was a severe case of swollen-head infection. The head is the confluence of all yang channels, and can be attacked only by wind. Yang in nature, the wind attacked the upper jiao first, while the heat in the lung and stomach flamed up

simultaneously. In this case, the triple-yang was affected. The formula prescribed was a modified Pŭ Jì Xiāo Dú Yĭn composed of jīng jiè suì 1.5 qian, fáng fēng 1 qian, chái hú 8 fen, huáng qín (wine-fried) 1.5 qian, huáng lián (wine-fried) 8 fen, jié gĕng 1 qian, lián qiào 3 qian, niú bàng zĭ (dryfried) 2 qian, mă bó 8 fen, gān căo 8 fen, jiāng cán (dry-fried) 3 qian, dà huáng (wine-fried) 3 qian, and băn lán gēn 3 qian. By the second visit, the swelling and other symptoms had improved since the day before. The formula prescribed on this visit was composed of jīng jiè suì 1.5 qian, fáng fēng 1 qian, bò he 8 fen, niú bàng zĭ (dry-fried) 2 qian, huáng qín (wine-fried) 1.5 qian, huáng lián (wine-fried) 8 fen, gān căo 6 fen, jié gĕng 1 qian, mă bó 8 fen, zhè bèi mŭ 3 qian, jiāng cán (dry-fried) 3 qian, lián qiào 3 qian, and băn lán gēn 3 qian. On the third visit, the swelling, aversion to cold with fever, thirst, and constipation disappeared, but the sore throat remained. The externally contracted pathogenic wind had been expelled, leaving flaming liver fire. The therapeutic method used was to clear heat and drain fire with a formula composed of sāng yè 3 qian, gān căo 6 fen, jīn yín huā 3 qian, jú huā 2 qian, jié gĕng 1 qian, lián qiào 3 qian, mŭ dān pí 1.5 qian, mă bó 8 fen, Dài Gé Săn 5 qian (wrapped separately), and zhú yè (fresh) 30 pieces.1 Comments: This is a case of swollen-head infection, caused by intense heat toxins in the lung and stomach. The therapeutic method used was to clear heat, resolve toxins, scatter wind, and disperse swelling. The formula prescribed was modified Pŭ Jì Xiāo Dú Yĭn. Doctor Ding added wine-fried dà huáng in the formula to enhance the power to clear heat toxins in the head and face, and then removed it as soon as the swelling was improved.

Xiān Fāng Huó Mìng Yĭn 仙⽅活命饮Immortal Formula Life-Giving Beverage Source Text Corrections and Annotations to Fine Formulas for Women (Jiào Zhù Fù Rén Liáng Fāng, 校注妇⼈良⽅)

Formula Ingredients

1 Wujin County Medical Association. Ding Gan-ren’s Case Records 丁⽢仁医案. Nanjing: Jiangsu Science and Technology Press; 1988.

Preparation and Administration

Decoct one dose of the formula with three bowls of Chinese wine, and boil it down to one and a half bowls. Take the decoction after meals for diseases in the upper part of the body. Take the decoction before meals for diseases in the lower part of the body, and then take three or four cups of Chinese wine to enhance the power of the decoction.

Formula Indications This formula is indicated for yang patterns in the initial stage with sores, abscesses, and ulcers. The symptoms are redness, swelling, and pain in the affected areas, fear of cold with fever, a thin white or yellow tongue coating, and a forceful, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is an initial stage of a yang pattern with sores, abscesses, and ulcers mainly caused by the accumulation and obstruction of heat toxins, as well as, qi stagnation, blood stasis, and phlegm coagulation. The heat toxins accumulate and obstruct causing a tangible accumulation of qi stagnation and blood stasis, which manifest as redness, swelling, and pain in the affected areas. The pathogenic qi struggles with the healthy qi in the fleshy exterior, causing fear of cold with fever and the intense pathogenic qi and healthy qi struggle within the channels, causing a forceful, rapid pulse. As the nature of the disease is a yang pattern of stagnant heat toxins in the fleshy exterior, the primary therapeutic method is to clear heat, resolve toxins, invigorate the blood, and regulate qi. The secondary method is to free the fleshy exterior, disperse swelling, and promote suppuration.

Formula Actions

Clears heat, resolves toxins, disperses swelling, promotes suppuration, invigorates blood, and relieves pain.

Formula Analysis

Unique Combination Features This formula primarily clears heat, resolves toxins, disperses swelling, promotes suppuration, invigorates the blood, and relieves pain. Secondarily, it vents the exterior, moves qi, dissolves phlegm, and dissipates masses. Since the features of the sore-resolving method used to treat abscesses and ulcers in yang patterns are all included in this formula, it is called the “best remedy for sores, abscesses, and ulcers, and the first choice among formulas for external diseases”[12].

Formula Applications

1. Essential pattern differentiation Xiān Fāng Huó Mìng Yĭn is a commonly used formula used to treat the initial stages of yang patterns with sores, abscesses, and ulcers. This clinical pattern is marked by:

● redness, swelling, and pain in the affected areas ● fear of cold with fever ● forceful, rapid pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient has a yang pattern or an excessive pattern of suppurative inflammation: cellulitis, suppurative tonsillitis, mastitis, impetigo, boils, and deep abscesses. 4. Cautions and contraindications This formula should be used during the initial stage of a yang pattern with sores, abscesses, and ulcers in those with an excess-type constitution. If the formula is used properly, “those (sores, abscesses, and ulcers) without pus will dissipate, and those (sores, abscesses, and ulcers) with pus will

drain.”[13] Do not use this formula for those with open sores, abscesses, and ulcers. For patients who do not like alcohol, decoct the formula with water, or with half Chinese wine and half water. In addition to the decoction, the medicinals in this formula can be ground into powder and applied to the affected areas. Since the nature of medicinals in this formula is primarily cool-cold, use the formula with caution in patients who have sores, abscesses, and ulcers in a yin pattern, as well as, those with spleen, stomach, qi, and blood deficiency.

Associated Formulas Wŭ Wèi Xiāo Dú Yĭn (Five Ingredients Toxin-Removing Beverage, 五 味消毒饮) [Source] Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) [Ingredients]

[Preparation and Administration] Prepare the medicinals as decoction with 1 zhong of water. Add 0.5 zhong wine when 80% water was left, then continue to boil it for a little while. Take it warm to induce sweat. [Actions] Clears heat, resolves toxins, and dissipates boils. [Applicable Patterns]

Boils caused by an accumulation of heat toxins. Symptoms include: hot, red, swollen, and painful boils, nail-like millet sores that have a firm root, a red tongue with a yellow coating, and a rapid pulse. Sì Miào Yŏng Ān Tāng (Four Wonderfully Effective Heroes Decoction, 四妙勇安汤) [Source] New Compilation of Proven Formulas (Yàn Fāng Xīn Biān, 验⽅新编) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat, resolves toxins, invigorates blood, and relieves pain. [Applicable Patterns] Sloughing deep-rooted abscesses caused by intense heat toxins. Symptoms include: hot, dark red, swollen limb, smelly ulcer with severe pain, fever and thirst, a red tongue, and a rapid pulse. Both Wŭ Wèi Xiāo Dú Yĭn and Sì Miào Yŏng Ān Tāng are commonly used formulas for treating sores in yang patterns. They both contain jīn yín huā, clear heat, and resolve toxins. Wŭ Wèi Xiāo Dú Yĭn primarily dissipates boils and is mainly indicated for boils caused by intense heat toxins. It is more powerful than Xiān Fāng Huó Mìng Yĭn in clearing heat and resolving toxins. Sì Miào Yŏng Ān Tāng is mainly indicated for sloughing deep-rooted

abscesses caused by intense heat toxins. The formula is composed of only a few medicinals at large doses. Its continuous use clears heat, resolves toxins, invigorates blood, and relieves pain.

Comparison & Contrast Pŭ Jì Xiāo Dú Yĭn vs. Xiān Fāng Huó Mìng Yĭn

Case Studies Fever after surgery of hepatic abscess Tang, a 17-year-old female, had her initial visit on September 24th, 1998. She had an operation to drain her hepatic abscess in the same hospital five years ago, which restored her health. One month ago, she developed a persistent fever that measured between 38.5°C and 39°C and pain in right upper quadrant. Her condition did not improve after receiving treatment in the inpatient department for five days, so doctor Wang was asked to give a consultation.

On the first visit, a physical examination revealed a fever without aversion to cold, pain in right upper quadrant, listlessness, poor appetite and digestion, edema of the feet, normal urine and stool, a thin yellow tongue coating, and a surging, rapid pulse. The pattern was an accumulation and obstruction of heat toxins, qi stagnation, blood stasis, flesh rotting, and suppuration. The therapeutic method used was to clear heat and resolve toxins, dissolve stasis and dissipate masses, and expel pus and toxins. The formula prescribed was a modified Xiān Fāng Huó Mìng Yĭn composed of jīn yín huā 30 g, lián qiào 30 g, pú gōng yīng 15 g, bèi mŭ 10 g, tiān huā fĕn 15g, dāng guī 10 g, chì sháo 10 g, mŭ dān pí 10 g, huáng qí 10 g, chuān shān jiă 5 g, zào jiăo cì 5 g, xiāng fù 10 g, and chén pí 10 g. On her second visit, her temperature was back to normal, the pain was remarkably relieved, and her appetite, digestion, and vigor were improved after ingesting four doses of the formula. Another four doses of the formula were given to the patient. On the third, fourth, and fifth visits the formula was modified according to the improvements in her condition. The patient fully recovered and went back home three weeks later.1 1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Physician: Zhang Qi’s Medical Cases 中国现代名中医医案精华. Beijing: Beijing Publishing House; 1990.

Comments: Abscesses, which literally indicate obstruction of qi and blood by toxins, can be divided into internal abscesses and external abscesses. External abscesses are on the body surface, while internal abscesses are inside zang-fu organs. This is a case of an internal abscess. The main symptom was pain in right upper quadrant, which was caused by an accumulation and obstruction of heat toxins, qi stagnation, blood stasis, flesh rotting, and suppuration. Jīn yín huā, lián qiào, and pú gōng yīng were used to clear heat and resolve toxins. Dāng guī, chì sháo, and mŭ dān pí were used to invigorate the blood and dissolve stasis. Xiāng fù and chén pí were used to enhance the ability to invigorate blood. Bèi mŭ and tiān huā fĕn were

used to clear heat, dissipate, and soften masses. Chuān shān jiă and zào jiăo cì were used to promote suppuration and drain pus. Huáng qí was used to draw the toxins outward. Since the formula combined medicinals to clear heat, resolve toxins, invigorate the blood, dissipate masses, promote suppuration, and drain toxins, the effect was good.

Section 4 Heat-Clearing Formulas that Clear Heat from the Zang-Fu Organs Heat-clearing formulas that clear heat from the zang-fu organs have the therapeutic effect to clear heat and drain fire. They are used for the condition of pathogenic heat in the zang-fu organs. Various heat-clearing medicinals are applied according to the location of the pathogenic heat. A pattern of intense heat in the heart channel manifests vexing heat in the chest, thirst and red complexion, sores in the mouth and tongue. Huáng lián, zhī zĭ, mù tōng, and lián zĭ xīn are used to clear and drain heart heat, as in the formula of Dăo Chì Săn. A pattern of excessive fire of the liver and gallbladder manifests pain in the chest and rib-side, headache, red eyes, and irritability and irascibility. Lóng dăn căo, xià kū căo, and qīng dài are used to clear and drain liver fire, as in the formulas Lóng Dăn Xiè Gān Tāng and Zuŏ Jīn Wán. A pattern of lung heat manifests cough and panting with yellow phlegm, or pus and blood. Sāng bái pí, wĕi jīng, and huáng qín are used to clear and discharge lung heat, as in the formulas Xiè Bái Săn and Wĕi Jīng Tāng. A pattern of heat accumulated in the stomach manifests as aphtha, bad breath, vexing heat, and rapid hungering. Shí gāo and huáng lián are used to clear and discharge stomach heat, as in the formula Qīng Wèi Săn and Yù Nǚ Jiān. A pattern of heat in the large intestine manifests as smelly, foul unformed stools, stools containing pus and blood, and a burning sensation in anus. Huáng lián, huáng qín, huáng băi, and bái tóu wēng are usually used to clear heat from the large intestine, as in the formulas Gé Gēn Huáng Qín Huáng Lián Tāng, Sháo Yào Tāng, and Bái Tóu Wēng Tāng.

Please note the following important aspects of medicinal combinations: 1. Protect the zheng qi When intense heat consumes yin and damages qi, lú gēn, huā fĕn, mài dōng, and shí hú can be added to clear heat, nourish yin, and promote fluid production. Rén shēn, jīng mĭ, and gān căo can be added to supplement qi and protect the stomach. Shēng dì and dāng guī can be added to nourish yin and blood. To prevent the cool-cold medicinals from damaging yang, wú zhū yú and ròu guì can be added as auxiliary inhibitory medicinals. 2. Dissipate fire depression For those with internal fire depression, shēng má and fáng fēng can be added to dissipate the depressed fire. 3. Combine medicinals according to the physiological and functional features of zang-fu organs The liver stores blood and governs the free flow of qi. As an example, we can consider that in patterns of liver pathology, medicinals such as dāng guī, shēng dì, and chái hú may be used in addition to medicinals that clear and drain liver fire since they generate blood, and promote qi and blood circulation.

Dăo Chì Săn 导⾚散Red-Guiding Powder Source Text Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀)

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. Decoct one dose (3 qian) of the formula with 1 cup of water and some zhú yè, boil until the volume is reduced to half. Drink the decoction warm, after meals. (Modern use: use water to decoct the medicinals, add zhú yè 3 g.)

Formula Indications This formula is indicated for intense heat in the heart channel. The symptoms are vexing heat in the chest, sores in the mouth and tongue, thirst, red complexion, preference for cold drinks, difficult and painful urination that is dark, a red tongue, and a rapid pulse.

Analysis of Fundamental Pattern Pathogenesis

This is a pattern of intense heat in the heart channel or the transmission of heart heat to the small intestine. The heart fire flames up along the channel and causes vexing heat in the chest, sores in the mouth and tongue, and a red complexion. The intense fire consumes yin, which causes thirst and a preference for cold drinks. Since there is an interior-exterior relationship between the heart and the small intestine, heart heat transmits to the small intestine, which fails to separate the clear and the turbid and cause difficult and painful urination with dark urine. The red tongue and rapid pulse are signs of internal heat. Qian Yi said the pathogenesis of this pattern is “heart heat” or “heat of the heart qi”, without defining the nature of the pattern in terms of deficiency or excess. Later, the Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) concluded this pattern is “deficient water without excessive fire”[14]; in other words, the yin deficiency and the fire are not severe. Children, whose yin and yang are tender, are more apt to contract cold and heat. Their diseases change rapidly, and may be either deficient or excessive. According to these features, Qian Yi established the therapeutic principle: prevent deficiency when treating excess, and prevent excess when treating deficiency for children’s diseases. Since the flaming of heart fire damages kidney yin, Qian Yi also suggested clearing heart fire together with nourishing yin, and promoting urination to drain heat.

Formula Actions Clears heart fire, nourishes yin, and promotes urination.

Formula Analysis

Unique Combination Features First, this formula clears heart fire while it nourishes yin, and it promotes urination to drain heat. Second, Dăo Chì Săn promotes urination without damaging the yin, and it nourishes yin without retaining pathogens.

Further Clarification There is a controversy as to which type of heart heat Dăo Chì Săn treats. Is it excessive fire or deficient fire? Regarding this question, there are three theories:

● excessive fire ● deficient fire ● deficient water without excessive fire Which is correct? As Qian Yi said, the pathogenesis of this pattern is “heart heat” or “heat of the heart qi”. Since he did not define the nature of

the pattern as deficiency or excess, it may be inappropriate to settle on a nature. In addition, in the Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀), the pattern of “excessive heart qi” described by Qian Yi uses only huáng lián in the listed formula, to treat excess. It differs from Dăo Chì Săn, which uses shēng dì and mù tōng. The comparison suggests that the pattern treated by Dăo Chì Săn is not excessive fire. On the other hand, Qian Yi said in chapter three of his book that “redness caused by heart heat should be treated with Dăo Chì Săn, and light redness caused by deficient heart heat should be treated with Shēng Xī Săn”[15]. That indicates that the pattern treated by Dăo Chì Săn is not deficient fire either. As a result, the pattern treated by Dăo Chì Săn may be “deficient water without excessive fire”, namely the yin deficiency and the fire are not severe. Since the yin deficiency is not severe enough to generate heat, and the fire is not excessive enough to damage yin, Dăo Chì Săn includes a large dose of sweet-cold shēng dì and bitter-cold mù tōng to nourish yin, inhibit fire, clear heart heat, and drain fire. The combination of medicinals in this formula has been formulated according to the features of children’s diseases. They change rapidly and are apt to be either deficient or excessive. It also adheres to the treatment principle of children’s diseases, which is to prevent deficiency when treating excess, and prevent excess when treating deficiency. In conclusion, “deficient water without excessive fire”[14] is an appropriate analysis for the pattern treated by Dăo Chì Săn.

Formula Applications 1. Essential pattern differentiation Dăo Chì Săn is a commonly used formula used to treat intense heat in the heart channel, and a commonly used formula that embodies the

therapeutic methods of clearing heat, promoting urination, and nourishing yin. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of intense heat in the heart channel: stomatitis, thrush, and night crying of babies; or when the patient shows signs of heart heat transmitting to the small intestine: acute urinary tract infection. 4. Cautions and contraindications Use this formula with caution in patients with spleen and stomach deficiency, as bitter-cold mù tōng and cool-cold shēng dì are included in the formula.

Associated Formulas Qīng Xīn Lián Zĭ Yĭn (Heart-Clearing Lotus Seed Beverage, 清⼼莲 ⼦饮)

[Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heart fire, nourishes qi and yin, and relieves strangury with turbid urine. [Applicable Patterns] Intense heart fire, deficiency of qi and yin, and damp-heat pouring downward. Symptoms include: seminal emission, stranguria with turbid urine, profuse uterine bleeding and leukorrhea, disease onset upon tiredness, kidney yin deficiency marked by thirst, vexation, and fever.

Case Studies Dental ulcers Shi, a 51-year-old male, who had suffered dental ulcers for half a year, had his initial visit on September 3rd, 2005. On his first visit, he reported that

he had dental ulcers a half a year ago, which were worse during ingestion, and swollen, sore gums. After taking some cydiodine, his condition was occasionally improved, his appetite and digestion became normal, he had unformed stool twice a day, and his urine was normal. Physical examination revealed scattered small dental ulcers, a pale tongue with a yellow coating, a red tongue tip, and a deep, thready pulse. The diagnosis was dental ulcers caused by the accumulation and evaporation of pathogenic heat (recurrent dental ulcers). When excessive thoughts consume yin and blood, the heart fire blazes to the upper body, transmits to the small intestine, which causes dental ulcers, and sores in the mouth and tongue. Prolonged heat consumes the stomach yin, which causes a recurrence of dental ulcers. The therapeutic method was to clear heat and drain fire. The formula prescribed was modified Dăo Chì Săn composed of shēng dì 15 g, tōng căo 6 g, zhú yè 9 g, lián qiào 12 g, cāng zhú 10 g, hòu pò 6 g, chén pí 5 g, gān căo 3 g, băi hé 20 g, zhī mŭ 6 g, dēng xīn căo 3 g, pú gōng yīng 15 g, and yì yǐ rén 15 g. (Five doses were prescribed; decoct the medicinals with water and take one dose per day.) By the second visit, after ingesting five doses of the formula, the pain of dental ulcers were remarkably relieved, the ulcers began to heal, the tongue body was pale and had a yellow coating, and the pulse was deep and thready. After ingesting another five doses of the formula, the patient recovered with no recurrence in half a year.1 Comments: Recurrent dental ulcers, a common condition, belong to the pattern of intense heat in the heart channel, and are typically coupled with constipation. Dăo Chì Săn is a commonly used formula used to treat intense heat in the heart channel. Since the fire consumes yin and fluids, the remedial effect will be better if medicinals that nourish yin and promote fluid production are included. Since the patient had unformed stools, Píng Wèi Săn was added to fortify the spleen and harmonize the stomach.

Lóng Dăn Xiè Gān Tāng 龙胆泻肝汤Gentian Liver-Draining Decoction Source Text Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ, 医⽅集解) 1 He Xing-dong, Weng Wei-liang, Yao Nai-li. Collection of Typical Case Records of Timehonored Famous Contemporary Physicians: Otorhinolaryngology 当代名⽼中医典型医案集-五官科 分册. Beijing: People’s Medical Publishing House; 2009.

Formula Ingredients

Preparation and Administration Use water to decoct the medicinals. The formula could also be prepared as pills as well. Take 1 dose (6-9 g) with warm water two times each day.

Formula Indications

1.Flaming up of excessive liver and gallbladder fire, which manifests as headache and red eyes, pain in the rib-side, bitter taste in the mouth, deafness, swelling of the ears, a red tongue with a yellow coating, and a forceful wiry, rapid pulse. 2.Pouring downward of damp-heat in the liver channel, which manifests as vaginal swelling and itching, dampness or sweating at the exterior genitalia, painful urination with turbid urine, impotence, smelly yellow leukorrhea, a red tongue with a yellow greasy coating, and a slippery, wiry, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern includes the flaming up of excessive liver and gallbladder fire and the pouring downward of damp-heat in the liver channel. The foot jueyin liver channel goes around exterior genitalia, goes along the rib-side, connects with the eyes, and enters the top of the head. The foot shaoyang gallbladder channel starts at the inner canthus, goes around the ears, and enters the ears. From there, one branch enters the femoribus internus and goes around the exterior genitalia, and the other branch runs along the ribside. The fire of the liver and gallbladder flames upward along the two channels which causes pain in the head, eyes, and ears; or deafness. Liver and gallbladder fire attacks the rib-side, which causes pain in rib-side and bitter taste in the mouth. Damp-heat in the liver channel pours downward along the channel, which causes vaginal swelling, itching, damp or sweat at the exterior genitalia, painful urination with turbid urine, impotence, and smelly yellow leukorrhea. A red tongue with a greasy yellow coating and a slippery, wiry rapid pulse are signs of intense fire and damp-heat. The characteristic features of this pattern pathogenesis are flaming up of excessive fire of the liver and gallbladder, pouring downward of damp-heat

in the liver channel, and a disturbance of the qi movement. Therefore, the therapeutic method is to clear and drain excessive fire of the liver and gallbladder, clear damp-heat in the liver channel, and free the qi movement.

Formula Actions Clears and drains excessive fire of the liver and gallbladder, and clears damp-heat in the liver channel.

Formula Analysis

Unique Combination Features This formula has three features:

● It clears excessive fire of the liver and gallbladder while it clears damp-heat in the liver channel.

● Discharges heat while it nourishes yin and blood (expels the pathogen without damaging the healthy qi).

● Drains fire downward with large doses of bitter-cold medicinals together with raising and freeing the qi movement of the liver and gallbladder.

Further Clarification If Lóng Dăn Xiè Gān Tāng is indicated for the flaming up of excessive fire of the liver and gallbladder, why are nourishing and moistening medicinals like dāng guī and shēng dì included? There are two reasons for using dāng guī and shēng dì:

● There are many bitter-dry medicinals in the formula that can damage liver yin.

● Since the liver is yin in form but yang in function, yin and blood are essential for the liver. Dāng guī and shēng dì are included to nourish yin and blood to supplement the liver’s form, and prevent damage to liver yin by the bitter-dry medicinals.

Formula Applications 1. Essential pattern differentiation Lóng Dăn Xiè Gān Tāng is a commonly used formula for treating the flaming up of excessive fire of the liver and gallbladder, or the pouring downward of damp-heat in the liver channel. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of flaming up of excessive fire of the liver and gallbladder: resistant brow ache, eczema in the head, hypertension, acute conjunctivitis, iridocyclitis, external auditory boils, and rhinitis; when the patient shows signs of damp-heat in the liver and gallbladder: acute icteric hepatitis, acute cholecystitis, acute posteriorganglionitis, acute mastitis, impotence; or when the patient shows signs of pouring downward of damp-heat in the liver channel: urinary tract inflammation, reproductive system inflammation, acute pyelonephritis, acute cystitis, urethritis, aidoiitis, orchitis, inguinal lymphadenitis, acute pelvic inflammatory disease, and Behcet’s disease. 4. Cautions and contraindications Do not use the formula in patients with deficiency-cold of the spleen and stomach, as well as those with yin deficiency and yang hyperactivity,

because there are many bitter-cold medicinals that can damage the spleen and stomach.

Associated Formulas Xiè Qīng Wán (Green-Draining Pill, 泻青丸) [Source] Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀) [Ingredients]

[Preparation and Administration] Grind these medicinals into powder and form into pills the size of a qiàn shí (1.5 g) using honey. Take 0.5-1 pills once with the decoction of zhú yè and sugar. [Actions] Clears the liver fire and drains fire. [Applicable Patterns] Fire constraint in the liver channel. Symptoms include: red swelling and painful eyes, vexation and irascibility, sleeplessness, dark urine and constipation, a surging excess pulse, acute infantile convulsion in children and convulsion caused by intense heat.

Dāng Guī Lóng Huì Wán ( Chinese Angelica, Chinese Gentian and Aloe Pill, 当归龙荟丸) [Source] Formulas from the Discussion Illuminating the Yellow Emperor’s Basic Questions (Huáng Dì Sù Wèn Xuán Míng Lùn Fāng, 黄帝素问宣明论⽅) [Ingredients]

[Preparation and Administration] Grind these medicinals into powder and form into pills the size of a bean using honey. Take 20 pills once with the decoction of shēng jiāng. [Actions] Clears excessive fire from the liver and gallbladder. [Applicable Patterns] Excessive fire in the liver and gallbladder. Symptoms include: dizziness, restlessness, delirious speech and mania, constipation, and difficult urination with dark urine. Both Xiè Qīng Wán and Dāng Guī Lóng Huì Wán are used for draining excessive fire from the liver channel, however there are certain differences between the two formulas. Xiè Qīng Wán is mainly indicated for internal liver fire constraint. It drains liver fire and scatters constrained liver and gallbladder fire. Dāng Guī Lóng Huì Wán is indicated for excessive fire in the liver channel. It is composed of many extremely cold and bitter

medicinals that primarily drain excessive fire through urination and defecation. Since Dāng Guī Lóng Huì Wán is a heavy formula for purging bowels, do not use the formula in patients who do not have a diagnosis of intense excessive fire.

Case Studies 1. Polycythemia rubra vera Wang, a 53-year-old male, had his initial visit on August 13th, 1974. He suffered with redness and heat on his face for three years. In addition, he also had a distending sensation, pain, and dizziness in his head for one year. Physical examination and laboratory examination revealed blood pressure between 140-160/100-120 mmHg, HGB was 206 g/L, RBC was 6.5×1012/L, WBC was 13.7× 109/L, and PLT was 235×109/L. The margin of his liver was 3 cm below the xiphoid process, the margin of his spleen 3 cm below the costal margin, and the spleen was of medium hardness. Bone marrow slides showed hyperactive proliferation of both E-CF and UGM-CFU. The diagnosis was polycythemia rubra vera. The patient had five venesections along with busulfanum, but his RBC count increased as soon as he stopped the medication. At his first visit, the patient had a headache and dizziness, dry throat with a bitter taste in the mouth, chest oppression and abdominal distention, gingival bleeding, red complexion, a dark red tongue body with a thin, white coating, and a deep, thready, wiry pulse. The HGB was 220 g/L, RBC was 6.09×1012/L, and PLT was 650×109/L. The pattern had depressed heat in the liver channel, and headache caused by blood stasis. The therapeutic method was to clear and drain liver heat, and invigorate the blood and dissolve stasis. The formula prescribed was a modified Lóng Dăn Xiè Gān Tāng composed of lóng dăn căo 12 g, huáng qín 12 g, zhī zĭ 12 g, chuān xiōng 20

g, yín chái hú 10 g, jīn yín huā 15 g, shēng dì 30 g, xuán shēn 15 g, jī xuè téng 25 g, é zhú 18 g, sān léng 18 g, bái máo gēn 15 g, ŏu jié 20 g, mŭ dān pí 10 g, and qīng dài 3 g. By the second visit, after ingesting 16 doses of the formula, the symptoms of headache, dizziness, dry throat, and bitter taste in the mouth were relieved. The blood pressure was 120-130/80-84 mmHg, HGB was 165 g/L, RBC was 5.59×1012/L, WBC was 7.5×109/L, and PLT was 102×109/ L. The patient had a dark red tongue with a thin white coating, and a deep wiry pulse. At this point, qīng dài was removed from the formula. By the third visit, the patient regained his vigor. After ingesting twenty doses of the formula, the headache and dizziness were completely relieved. HGB was 119 g/L, RBC was 4.09×1012/L, WBC was 7.05×109/L, and PLT was 108×109/L. The patient had a dark red tongue with a thin white coating and a deep wiry pulse. This time, zé xiè 10 g and chì sháo 15 g were added to the formula. He was asked to take a half-dose of the formula each day. During his one-year follow-up visit, he took two doses of the formula every week, and the count of HGB ranged between 120-146 g/L, RBC ranged between (4.2–5.4 )×1012/L, and PLT ranged between (160–183)×109/L.1 Comments: This disease was caused by hyperactive hematogenesis in the bone marrow, which caused an increase in RBC count, WBC count, HGB count, and blood viscosity. The patient suffered from a distending sensation, pain, and dizziness in the head, and a bitter taste in the mouth, dry throat, constipation, nosebleed, hypertension, enlarged dusky tongue with stasis macules, and a deep thready, wiry pulse. This was an excess pattern associated with liver heat, liver fire, and blood stasis that would commonly be treated by unblocking the bowels and discharging heat. But given the long course of the chronic disease, it is important to minimize the damage to qi and blood. Therefore, the purgative method was not used for a long period

of time, and the use of purgative medicinals was stopped as soon as the stool lost form. For the excessive fire of the liver and gallbladder with severe damp-heat and blood stasis, táo rén, hóng huā, é zhú, and sān léng were added to Lóng Dăn Xiè Gān Tāng. For the yin deficiency, xuán shēn and mài dōng were added. For the severe nosebleed, bái máo gēn, ŏu jié, and mŭ dān pí were added. For the fatigue and spleen deficiency, rén shēn and huáng qí were added. For the decreased RBC and HGB count, and increased WBC count, căo hé chē and lián qiào was added; and qīng dài has very good effect on this disease. Set aside the qīng dài and decoct the rest of the medicinals, filter the decoction, then add the qīng dài 12 g and continue the decoction for another 15 minutes; or alternatively, infuse qīng dài 3 g in the decoction. Discontinue the formula (in this regiment) as soon as the condition is fully relieved and, continue using the formula for at least one year by taking one dose every two or three days. Doctor Guo used Lóng Dăn Xiè Gān Tāng to treat five cases of polycythemia rubra vera, and achieved clinical efficacy in every case. 1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Physician: Zhang Qi’s Medical Cases 中国现代名中医医案精华. Beijing: Beijing Publishing House; 1990.

2. Alopecia Cai, 20-year-old female, had her initial visit on March 14th, 1977. The patient suffered from alopecia for two years. The condition was mainly focused at the top of head, more hair would fall out when she combed her hair, washed her hair, and when she scratched her scalp. When the alopecia became severe, the patient showed symptoms of sallow yellow skin and complexion, poor appetite, and listlessness. These symptoms improved when the alopecia improved. The patient took many formulas to boost qi and nourish the blood, enrich and nourish the liver and kidney, and nourish the

blood and dispel wind. She also took dicysteine, vitamins, and even applied ginger onto the affected scalp. Unfortunately, none proved to be effective. On her first visit, she had a poor appetite, bitter taste in the mouth, thirst, sticky sensation in the mouth in the morning, scant dark urine, and burning sensation of urination. Physical examination and laboratory examination revealed scant hair at the top of head, a shining scalp at the affected areas, no scars or squamae, loose connection between hair roots and the scalp, hair pulled out easily, a light red tongue with a thick, greasy yellow coating, and a wiry, tight, rapid pulse. The pattern was differentiated as damp-heat retention in the spleen and stomach, and deficient source of qi and blood. The therapeutic method was to clear heat and drain dampness. The formula prescribed was a modified Lóng Dăn Xiè Gān Tāng composed of lóng dăn căo 6 g, zhī zĭ 9 g, huáng qín 9 g, shēng dì 12 g, chē qián căo15 g, zé xiè 9 g, mù tōng 6 g, gān căo 3 g, dāng guī 9 g, chái hú 9 g, bì xiè 12 g, and chì xiăo dòu 15 g. (Ten doses.) On the second visit, after she ingested 10 doses of the formula, the greasy yellow tongue coating disappeared, the pulse became soft and thready, her appetite improved, the thirst and bitter taste disappeared, urine normalized, short tender hair began to grow in the affected scalp, and her hair loss remarkably decreased when she combed hair. Shēn Líng Bái Zhú Săn was then given to the patient in an effort to achieve a full recovery. In a follow-up exam, it was noted that she fully recovered with no recurrence of the alopecia.1 Comments: The steaming up of damp-heat caused this disease. The patient had a prolonged deficiency of the spleen and stomach, which caused the damp-heat to steam up to the top of the head and the hair to fall out from a lack of nourishment. After Lóng Dăn Xiè Gān Tāng was given to clear heat and drain dampness, the source of the qi and blood was restored, normal

function was restored, and her hair regained nourishment. As a result, her hair began to grow again. Shēn Líng Bái Zhú Săn was then given to eliminate the source of the phlegm production, which achieved a good result. When treating patients with alopecia, do not limit the therapeutic method to the classical principle of nourishing and supplementing the liver and kidney, nourishing the blood and dispelling wind, and boosting qi and promoting the blood production. A good effect can only be achieved when the treatment targets the cause and pattern of the disease accurately.

Zuŏ Jīn Wán 左⾦丸Left Metal Pill Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法) 1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Physician: Zhang Qi’s Medical Cases 中国现代名中医医案精华. Beijing: Beijing Publishing House; 1990.

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. Use the powder to make pills with water or steam the powder into pills. Take 50 pills each time with warm water. (Modern use: take powder directly, 3 g to 6 g per time, twice a day. Otherwise, use water to decoct huáng lián 6 g and wú zhū yú 1 g).

Formula Indications This formula is indicated for liver fire invading the stomach, which causes burning pain in the rib-side, vomiting and bitter taste in the mouth, epigastric upset and acid swallowing, a red tongue with yellow coating, and a wiry, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis

This is a pattern of liver constraint transforming into fire. Liver fire runs across and invades the stomach, which causes liver-stomach disharmony. Since the liver channel runs along the rib-side, fire constraint in the liver channel causes burning pain in the region. Liver fire invades the stomach and the stomach qi fails to descend, which causes epigastric upset, acid swallowing, vomiting, and bitter taste in the mouth. A red tongue body with a yellow coating and a wiry, rapid pulse are signs of fire constraint in the liver channel. In this pattern, the liver fire is the root, and the counterflow of the stomach qi is the branch. Therefore, the therapeutic method is to clear and drain liver fire, direct counterflow downward, and arrest vomiting.

Formula Actions Clears and drains liver fire, directs counterflow downward, and arrests vomiting.

Formula Analysis

Unique Combination Features This formula has two features. First, the formula includes acrid medicinals to open and bitter medicinal to promote descent. The liver and stomach are treated at the same time. Second, the formula drains fire without

retaining pathogens, and it directs counterflow downward without worsening the fire constraint. The opposites are complementary to each other.

Formula Applications 1. Essential pattern differentiation Zuŏ Jīn Wán is a commonly used formula used to treat liver fire invading the stomach, and liverstomach disharmony. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver fire invading the stomach: gastritis, esophagitis, and gastric ulcers. 4. Cautions and contraindications Do not use this formula in patients with acid swallowing caused by deficiency-cold of the stomach.

Associated Formulas Wù Jĭ Wán (Wu Ji Pill, 戊⼰丸)

[Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Grind these medicinals into powder and form into pills the size of a phoenix tree seed using honey. Take 20 pills (6 g) with thick rice water three times per day. [Actions] Scatters liver qi, rectifies spleen qi, clears heat, and harmonizes the stomach. [Applicable Patterns] Liver-spleen disharmony. Symptoms include: stomachache, acid swallowing, abdominal pain, and diarrhea. Xiāng Lián Wán ( Costus Root and Coptis Pill, ⾹连丸) [Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration]

Fry huáng lián with wú zhū yú, and then remove wú zhū yú and add mù xiāng. [Actions] Clears heat, removes dampness, moves qi, and resolves stagnation. [Applicable Patterns] Damp-heat dysentery. Symptoms include: stool with pus and blood, abdominal pain, abdominal urgency with rectal heaviness, tenesmus. Both Wù Jĭ Wán and Xiāng Lián Wán include acrid medicinals to open and bitter medicinal to promote descent. However, there are certain differences between them. In Wù Jĭ Wán, huáng lián and wú zhū yú are used in the same dosage. It equally clears heat and resolves constraint. Bái sháo is used for harmonizing the center and relaxing tension. It is indicated for liverspleen disharmony marked by stomachache, acid swallowing, abdominal pain, and diarrhea. In Xiāng Lián Wán, huáng lián and wú zhū yú are fried together, and then wú zhū yú is removed. Its primary function is to clear heat and dry dampness. Mù xiāng is used to move qi and relieve pain. This formula is indicated for damp-heat dysentery marked by stool with pus and blood, abdominal pain, and abdominal urgency with rectal heaviness

Comparison & Contrast Lóng Dăn Xiè Gān Tāng vs. Zuŏ Jīn Wán

Case Studies Vomiting Du, a 4-year-old male, had his initial visit on August 18th, 2001. He suffered for two months from paroxysmal headaches, occasional vomiting, vexation, irascibility, irritability, white patches scattered on the face, pale complexion, a red tongue with a thin yellow coating, and a wiry, rapid pulse. The pattern was differentiated as flaming up of liver fire and vigorous wood restricting earth. The therapeutic method used was to clear and drain the liver fire, soothe the liver, and regulate the spleen. The formula prescribed was a modified combination of Zuŏ Jīn Wán and Sì Nì Săn. The prescription was composed of chái hú 8 g, zhĭ qiào 8 g, bái sháo 8 g，gān căo 8 g, huáng lián 4 g, wú zhū yú 1 g, chuān xiōng 15 g, xì xīn 2 g, quán xiē 3 g,

màn jīng zĭ 6 g, and yuán hú 6 g. (7 doses. The medicinals were decocted with water, and he took one dose each day.) After ingesting seven doses of the formula, the headache was relieved and the frequency of vomiting was decreased. However, the patient was still vexed, irascible, and irritable. Add zhī zĭ 6 g and chán tuì 3 g in the formula to scatter wind and drain fire. After another fourteen doses, the patient fully recovered, with no recurrence over the following two months.1 Comments: The liver prefers free activity. Therefore, it is averse to depression, and when it is depressed, its qi easily ascends. For this reason, “the liver is the unyielding viscus.”[16] Harmony of the body’s qi mechanism is associated with the ascending and descending free flow of the liver qi. Irritability inhibits the qi mechanism and dampers the liver’s activity. The liver qi becomes constrained and bound, which will then transform into fire. According to the Case Records as a Guide to Clinical Practice (Lín Zhèng Zhĭ Nán Yī Àn, 临证指南医案), “binding constraint of qi causes qi stagnation, which will surely transform into fire over a course of time.”[17] Since the nature of fire is to flame upward, fire harasses the brain and causes headaches. Overactive wood restricts earth and the deficient spleen fails to transport, which causes a pale complexion, and white patches on the face. Liver fire invades the stomach, producing occasional vomiting. Doctor Xue typically focuses on the harmony of the liver and spleen. In this case, Doctor Xue used Zuŏ Jīn Wán and Sì Nì Săn to harmonize the liver and spleen, unblock the collaterals, and relieve pain. In his prescription, huáng lián 6 g and wú zhū yú 1 g were used to treat the liver fire invading the stomach, and wú zhū yú was used as a paradoxical assistant and channel envoy. This is a good example that effectively demonstrates the theory that opposites can be used complementary to each other.

Wĕi Jīng Tāng 苇茎汤Phragmites Stem Decoction Source Text (Invented in) Ancient and Modern Records of Proven Formulas (Gŭ Jīn Lù Yàn Fāng, 古今录验⽅) (Recorded in) Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘要)

Formula Ingredients

Preparation and Administration Grind the medicinals into crude powder. Decoct one dose of the formula with phragmites stem juice, and boil it until the volume shrinks to about 2 sheng (400 ml). Take 1 sheng (200 ml) first. Then after taking the other 1 sheng (200 ml) of the decoction, the patient will surely spit pus. (Modern use: use water to decoct the medicinals.)

Formula Indications 1 Lu Lei, Liu Zhi-qin. Clinical Sample of Zuŏ Jīn Wán by Prof. Xue Bo-shou薛伯寿教授临床妙 ⽤左⾦丸. Guangming Journal of Chinese Medicine. 2003; 18(2): 61.

This formula is indicated for lung abscesses, and patterns of accumulation and obstruction of heat toxins, binding of phlegm, and blood stasis. The symptoms are coughing with profuse phlegm, coughing or spitting up of foul smelling pus and blood, dull pain in the chest, a red tongue with a greasy yellow coating, and a slippery, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis The pattern of lung abscess, which is caused by the accumulation and obstruction of heat toxins, binding of phlegm, and blood stasis, is mainly seen in the stage when an abscess is formed in the lung. Phlegm-heat accumulates in the lung, and the lung qi fails to purify, causing a cough with profuse phlegm. Pathogenic heat invades the lung, burns the blood vessels, and causes an accumulation of heat and blood stasis. The prolonged accumulation of heat and blood stasis leads to the formation of the lung abscess as flesh and blood rot. The abscess breaks and pus exits body through the mouth, causing a cough or the spitting up of smelly pus and blood. Phlegm-heat and blood stasis bind with each other in the chest and causes dull pain in the chest. A red tongue body with a greasy yellow coating and a slippery, rapid pulse are signs of intense phlegm-heat. Therefore, the therapeutic method is to clear lung heat, dissolve phlegm, and expel stasis and pus.

Formula Actions Clears lung heat, dissolves phlegm, expels stasis, and dissipates masses.

Formula Analysis

Unique Combination Features This formula, mild in nature, combines the heat-clearing, phlegmdissolving, and bloodexpelling therapeutic methods. It reflects the abscessresolving method used for lung abscesses once pus has formed.

Formula Applications 1. Essential pattern differentiation Wĕi Jīng Tāng is a commonly used formula used to treat lung abscess, whether pus has formed or not. This clinical pattern is marked by:

● fullness and pain in the chest ● cough and breathlessness ● coughing or spitting up of thick yellow or yellow-green phlegm ● fishy smell in the throat ● red tongue with greasy yellow coating ● slippery rapid pulse

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of binding heat, dampness, and blood stasis in the lung: pulmonary abscess, pneumonia, acute bronchitis, secondary infection on the basis of chronic bronchitis, acute suppurative tonsillitis, and nasosinusitis.

Associated Formulas Jié Gĕng Tāng (Platycodon Decoction, 桔梗汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略⽅论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Diffuses the lung, relieves cough, dispels phlegm, and evacuates pus. [Applicable Patterns]

Lung abscess. Symptoms include: cough and chest pain, cold shivering, dry throat without thirst, cough or spitting up of smelly pus and blood, or pasty sputum.

Case Studies Cough/mycoplasmal pneumonia Wu, a 15-month-old female, had her initial visit on August 17th, 2005. She had been coughing for over 20 days. The patient had a fever, cough, and breathlessness on July 20th, 2005. After treatment with Western medicine, her temperature returned to normal, but the cough did not improve. The patient showed poor appetite and digestion, normal sleep, urine, and stool, a red tongue with a thin yellow coating, and floating, slippery, rapid pulse. The mycoplasma pneumonia antibody was positive, and the X-ray radiograph indicated mycoplasma pneumonia in both lungs. The diagnosis was cough (mycoplasma pneumonia). This pattern was caused by wind-warmth invading the lung, failure of the lung to diffuse and govern descent, and the accumulation of phlegm-heat in the lung. As the disorder of the child-organ affecting the mother-organ, the spleen and stomach failed to govern the decomposition, transportation, and transformation of food and drink, causing poor appetite and digestion. The therapeutic method used was to clear lung heat, dissolve phlegm, direct qi downward, and relieve the cough. The formula was a modified Wĕi Jīng Tāng composed of wĕi jīng 10 g, dōng guā rén 15 g, yì yĭ rén 15 g, guā lóu rén 10 g, chuān bèi mŭ 10 g, zĭ sū gĕng 8 g, kŭ xìng rén 8 g, bàn xià 8 g, mài mén dōng 10 g, wū méi 5 g. The medicinals were decocted with water. One dose was taken each day. By the second visit, after ingesting two doses of the formula, her cough and breathlessness had improved. They were the result of impaired phlegmheat, so Èr Chén Tāng was added to the formula this visit. After ingesting

another four doses of the newly modified formula, the cough was further improved and the breathing normalized, the appetite and digestion had not improved, and the pulse was thready and weak. These symptoms indicated that although the pathogenic heat had been eliminated, there was still deficiency of the spleen and stomach, and residual phlegm. Therefore, Doctor He changed the formula to Shēn Líng Bái Zhú Săn combined with Chén Xià Liù Jūn Zĭ Tāng in order to boost the lung, direct qi downward, and dissolve phlegm. After taking five doses of the formula, the cough was markedly relieved, and the appetite and digestion were back to normal. The complexion and pulse of the patient was restored normal. A modified Chén Xià Liù Jūn Zĭ Tāng was given to the patient in order to supplement and boost the spleen and lung, dissolve phlegm, and relieve the cough in order to consolidate the effect.1 Comments: This case has two points worthy of emphasis. First, Wĕi Jīng Tāng can be used to treat severe cases of obstruction in the lung caused by the invasion of pathogenic toxins, such as a lung abscess or lung cancer. The formula could be modified according to specific conditions. Since the patient was a child, and the case was not a chronic disease, the bloodinvigorating táo rén was replaced with damp-heat-clearing guā lóu rén. Second, children who have delicate yin and yang are apt to contract cold and heat, apt to contracting either a deficient or excessive pattern, and apt to have deficiency of the spleen. Therefore, when the majority of the pathogens had been expelled, the therapeutic method changed to prescription that primarily supplemented the spleen and stomach, and secondarily expelled pathogens.

Xiè Bái Săn 泻⽩散White-Draining Powder Source Text Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀)

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. Decoct one dose of the formula with a few jīng mĭ and 2 zhan of water, and boil it until the volume shrinks to about 70%. Take the decoction before meals. (Modern use: use water to decoct the medicinals.)

Formula Indications 1 Sun Guang-rong, Yang Long-hui, Ma Jing. Collection of Typical Case Records of TimeHonored Famous Contemporary Physicians: Pediatrics 当代名⽼中医典型医案集-⼉科分册. Beijing: People’s Medical Publishing House; 2009.

This formula is indicated for coughing and panting caused by lung heat. The symptoms are coughing, panting, and steaming heat of skin that worsens in the late afternoon, a red tongue body with a yellow coating, and a thready, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis

This is a pattern of heat constraint and fire retention in the lung. The heat is constrained in the lung, which causes qi to counterflow and produce coughing and panting. Lung heat steams outward to the skin, resulting in steaming heat of the skin. Different from exterior heat, retained interior heat gradually consumes yin, which increases the steaming heat in the late afternoon. When the skin is first touched, steaming heat is evident by the warmth that is initially felt. However, the heat sensation decreases over a period of time. This characteristic makes this type of steaming heat different from the steaming heat of yangming, which increases over time. A red tongue body with a yellow coating and a thready, rapid pulse are signs of consumption of yin by pathogenic heat. Therefore, the therapeutic method used is to clear and drain heat constraint, and to relieve coughing and panting.

Formula Actions Clears and drains the heat constraint and relieves coughing and panting.

Formula Analysis

Unique Combination Features

Xiè Bái Săn combines heat-clearing medicinals with yin-nourishing medicinals, and heatdraining medicinals with spleen-supplementing medicinals. It banks up earth to generate metal, and harmonizes both the lung and spleen. The formula is neither designed for clearing excessive lung heat in order to treat the branch, nor nourishing the lung yin in order to treat the root. The target of the formula is to eliminate heat constraint by clearing retained lung fire.

Further Clarification Can Xiè Bái Săn really drain heat from the lung? This is a controversial problem. Luo Qian-fu thought the formula “had no reason to drain lung heat”, but Wu Ju-tong thought the formula “is too powerful to drain lung heat”, and explained it in an article titled “Do Not Use Xiè Bái Săn at Will”. Which theory is correct? According to the Treatise on Medicinal Properties (Yào Xìng Lùn, 药性论), sāng bái pí “is used for treating panting and fullness caused by the failure of lung qi to descend, as well as edema caused by dampness”. According to the textbook Chinese Materia Medica, sāng bái pí “is used for draining lung heat and relieving panting”. As recorded in Materia Medica for Decoctions (Tāng Yè Bĕn Căo, 汤液本草), dì gŭ pí could “drain kidney fire and clear retained fire in the lung”. On the other hand, both sāng bái pí and dì gŭ pí are sweet-cold and heat-clearing medicinals that enter the lung channel. The formula could surely clear lung heat, but it is not “too powerful to drain lung heat”. This is because the medicinals included in the formula are all sweet-cold or sweet. The formula combines heat-draining medicinals with spleensupplementing medicinals like gān căo and jīng mĭ. In conclusion, the formula can moderately drain lung heat. Xiè Bái Săn can be used to treat panting in an exterior pattern by adding exteriorreleasing medicinals in the formula.

Golden Mirror of the Medical Tradition- Essential Teachings on Miscellaneous Diseases (Yī Zōng Jīn Jiàn- Zá Bìng Xīn Fă Yào Jué, 医宗⾦ 鉴·杂病⼼法要诀) gave an example of such a condition: “those with an absence of sweating indicates a pattern of lung fire constrained by external cold. Add má huáng and xìng rén in Xiè Bái Săn to release exterior pathogens.”[18]

Formula Applications 1. Essential pattern differentiation Xiè Bái Săn is a commonly used formula used to treat coughing and panting caused by retained fire in the lung. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of fire retention in the lung and damage to the qi and yin: bronchitis, early stage pneumonia, and early stage rubeola in children. 4. Cautions and contraindications

Do not use the formula in patients with a cough caused by wind-cold or deficiency of the lung.

Associated Formulas Tíng Lì Dà Zăo Xiè Fèi Tāng (Lepidium/Descurainiae and Jujube Lung-Draining Decoction, 葶苈⼤枣泻肺汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Add 3 sheng of water to boil dà zăo until 2 sheng of water remained. Remove dà zăo and add tíng lì zĭ and decoct it until 1 sheng of water left and take it. [Actions] Drains the lung, moves water, lowers qi, and relieves panting. [Applicable Patterns] Profuse phlegm and dampness. Symptoms include: panting, coughing, and chest fullness.

Qīng Wèi Săn 清胃散Stomach-Heat-Clearing Powder Source Text Treatise on the Spleen and Stomach (Pí Wèi Lùn, 脾胃论)

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine powder. Decoct one dose of the formula with 1.5 zhan of water, and boil it until the volume shrinks to 70%. Filter the decoction and take it once the decoction cools. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for toothaches caused by stomach fire. The symptoms are toothache radiating to the head, aversion to heat and a preference for cold on the teeth, bad breath that is hot, heat in the face, thirst, gingival atrophy bleeding, redness, swelling, and ulcers in the gum, swelling and pain in lips, tongue, and cheeks, a red tongue with a yellow coating, and a slippery, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of heat accumulation in the stomach, heat constraint, blood heat, and heat attacking upward along the channels. The foot yangming stomach channel goes around the nose, enters the upper teeth, goes along the front of the ears, forehead, and around the lips. The hand yangming large intestine channel goes along the cheeks and connects with the lower teeth. Stomach fire and blood heat attack upward along the stomach and large intestine channels, which causes toothaches, swelling and pain in the lips, tongue, and cheeks, bad breath that is hot, thirst, and ulcers in the gum. Since the toothache is caused by heat, the pain is relieved by cold and worse with heat. Therefore, the teeth have an aversion to heat and a preference for cold. The foot yangming stomach channel goes along the hairline to the forehead, this is why the toothache radiates to the head and why the heat reaches the face. Since the stomach is rich in qi and blood, intense stomach fire burns blood vessels, which causes gingival bleeding. The red tongue with yellow coating and the slippery, rapid pulse are signs of intense stomach fire. The characteristic features of this pattern’s pathogenesis are stomach fire and blood heat attacking upward along the channels.

Formula Actions Drains stomach fire and cools blood.

Formula Analysis

Unique Combination Features This formula combines medicinals that clear the qi level with medicinals that cool blood, bitter descending medicinals with ascending medicinals that scatter, and medicinals that drain fire with medicinals that nourish yin and blood.

Further Clarification What is the chief medicinal in Qīng Wèi Săn? This is a controversial issue. Some say the chief medicinal is shēng dì (as recorded in the Deletion and Supplement to the Discussion on Famous Physicians’ Formulas, Shān Bŭ Míng Yī Fāng Lùn, 删补名医⽅论), and some said it is shēng má (as recorded in the Treatise on Blood Syndromes, Xuè Zhèng Lùn, ⾎证论), and yet others said it is huáng lián (as recorded in the Medical Formulas Collected and Analyzed, Yī Fāng Jí Jiĕ, 医⽅集解). Which is correct? According to the Treatise on the Spleen and Stomach (Pí Wèi Lùn, 脾胃论), the theory is recorded in the Medical Formulas Collected

and Analyzed. It states the reason is that Qīng Wèi Săn is indicated for clearing stomach fire; and huáng lián, which is an effective medicinal to clear the stomach targets both the cause and the main symptoms of the pattern that Qīng Wèi Săn treats. Additionally, huáng lián is a commonly used medicinal that is applicable for patterns of excessive heat in the stomach. For these reasons, huáng lián should be the chief medicinal in Qīng Wèi Săn. Shēng má has the effect to clear heat and resolve toxins, but it also has the effect to scatter and promote ascension, which may enhance the upward momentum of the flaming stomach fire. On the other hand, the effect of shēng má does not fit the pattern treated by Qīng Wèi Săn very well, which is the flaming up of the stomach heat. Only huáng lián can balance the paradox faced by shēng má. Therefore, although mild shēng má is used at a large dose in Qīng Wèi Săn, it is not the chief medicinal; but rather the deputy medicinal in the formula.

Formula Applications 1. Essential pattern differentiation Qīng Wèi Săn is a formula used to treat the toothache and gingival atrophy caused by stomach fire and blood heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of stomach fire and blood heat attacking upward along the channels: stomatitis, periodontitis, trigeminal neuralgia, and acne. 4. Cautions and contraindications Do not use this formula for patients with a toothache caused by windcold and deficient kidney fire.

Associated Formulas Xiè Huáng Săn (Yellow-Draining Powder, 泻黄散) [Source] Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀) [Ingredients]

[Preparation and Administration]

Cut the medicinals into pieces and fry them with honey and wine, then grind them into powder. Take 1-2 qian (3-6 g) once with water. [Actions] Drains latent fire of the spleen and stomach. [Applicable Patterns] Latent fire of the spleen and stomach. Symptoms include: sore mouth, bad breath, vexation and thirst, rapid hungering, dry lips and mouth, a red tongue body, a rapid pulse, and a waggling tongue caused by spleen heat.

Case Studies Acne Jia, an 18-year-old female student, had her initial visit on March 15th, 1992. She suffered from acne on her cheeks and forehead for over two years. At first, the acne had black papules that would secrete a milky white powderlike substance when squeezed. Near the time of her visit, her condition had been worse with more acne and newly affected areas on the skin of her chest and back. Physical examination revealed scattered black heads, acnes, papules, pustules, nodules, and cysts on the face, itching of the pantomorphic skin lesions, hot flashes on the face, vexation and thirst, constipation, dark urine, a red tongue with a yellow coating, and a wiry, rapid pulse. The pattern was accumulated heat in the lung and stomach steaming upward to the face and heat constraint in the facial skin. The therapeutic method was to clear and drain heat constraint of the lung and stomach, cool blood, disperse swelling, and relieve itching. The formula prescribed was modified Qīng Wèi Săn composed of huáng lián 6 g, shēng dì 30 g, mŭ dān pí 15 g, dāng guī 10 g, shēng má 10 g, sāng bái pí 10 g, dà

huáng 6 g, huáng qín 6 g, lián qiào 10 g, bái xiān pí 30 g. Decoct the medicinals with water, and take one dose two times a day. After ingesting three doses of the formula, all of her symptoms improved; the pantomorphic skin lesions were partially eliminated, and there were no acne outbreaks. After another five doses of the formula, the patient fully recovered.1 Comments: Acne, a common skin disorder among males and females during puberty, was called “lung wind acne” and “alcohol acne” in traditional Chinese medicine. The main causes are an irregular diet and a large amount of sweet, greasy, and spicy food in the diet. This leads to an accumulation of heat in the intestines, which fail to move downward and then cause an accumulation of damp-heat in the lung and stomach. The heat, which can neither be expelled through the exterior nor drained from the interior, steams to the skin and becomes constrained there. The therapeutic method is to clear and drain heat constraint in the stomach, cool blood, and disperse swelling. The formula prescribed was a modified Qīng Wèi Săn. In the formula, huáng lián was used to clear and drain stomach fire. Shēng dì, dāng guī, mŭ dān pí, and shēng má were used to clear heat, cool blood, invigorate the blood, disperse swelling, dissipate masses, promote blood circulation, and promote skin secretion. Sāng bái pí and huáng qín were used to enhance the ability to clear and drain the heat constraint from the lung and stomach. Lián qiào, the “best remedy for sores, abscesses, and ulcers”, was used to release the exterior and drain heat. Dà huáng was used to clear heat, resolve toxins, unblock the interior, and to purge. Bái xiān pí was used to clear heat, eliminate dampness, and relieve itching. The formula cleared heat, resolved toxins, unblocked the interior through purgation, cooled the blood, and dispersed swelling. As a result, the heat constraint in the lung and

stomach was cleared and the heat constraint in the blood was scattered. Therefore, the acne was cured, as were the accompanying symptoms.

Yù Nǚ Jiān ⽟女煎Jade Lady Decoction Source Text The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书)

Formula Ingredients

1 Leng Chong-fen, Liu Fang-gui. Two successful cases of Using Qīng Wèi Săn 清胃散治验⼆则. Yunnan Journal of Traditional Chinese Medicine and Materia Medica. 1995; 16(3): 31-32.

Preparation and Administration Decoct one dose of the formula with 1.5 zhong of water, and boil it until the volume shrinks to about 70%. The decoction can be taken either warm or cool. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for stomach heat and yin deficiency. The symptoms are toothache, headache, loose teeth, gingival bleeding, vexing heat and thirst, a red tongue with a dry yellow coating, xiāo kĕ, and swift digestion with rapid hungering.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of shaoyin deficiency and yangming excess. Since the yangming channels go upward to the head and face, excessive heat of yangming stomach attacks upward to the head and face causing toothaches and headaches. Heat burns the blood vessels along the stomach channel, which caused gingival bleeding. Kidney yin deficiency causes the teeth to become loose. The stomach governs the intake of food and drink, excessive stomach heat causes swift digestion with rapid hungering. Heat consumes yin and fluids, causing vexing heat, thirst, and a red tongue with a dry yellow coating. This pattern is caused by the interaction between excessive fire and yin deficiency, with stomach heat as the main cause. Therefore, the therapeutic method is to clear stomach heat as the primary focus, and nourish kidney yin as the supplementary focus.

Formula Actions Clears stomach heat and nourishes kidney yin.

Formula Analysis

Unique Combination Features This formula is able to simultaneously clear heat and nourish yin, and supplement deficiency while reduce excess; however, it primarily reduces excess.

Formula Applications 1. Essential pattern differentiation Yù Nǚ Jiān is a commonly used formula used to treat toothache, gingival bleeding, and xiāo kĕ caused by stomach heat and yin deficiency. This clinical pattern is marked by:

● loosening of the teeth ● vexing heat and thirst ● red tongue body with dry yellow coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of stomach heat and yin deficiency: gingivitis, diabetes mellitus, acute stomatitis, and glossitis. 4. Cautions and contraindications Do not use the formula for patients with thin, unformed stool caused by deficiency of the spleen.

Comparison & Contrast Qīng Wèi Săn vs. Yù Nǚ Jiān

Gé Gēn Huáng Qín Huáng Lián Tāng 葛根黄芩黄 连汤Pueraria, Scutellaria, and Coptis Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Decoct gé gēn with 8 sheng (1600 ml) of water until the volume shrinks to about 6 sheng (1200 ml). Then decoct the other medicinals in the formula with the gé gēn decoction, and boil it down until the volume to about 400 ml. Filter the decoction and take it warm. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for diarrhea with fever. The symptoms are diarrhea, fever, smelly, foul, thick, and sticky stool, burning sensation in the anus, panting with sweating, vexing heat in the chest and stomach cavities, thirst, dark urine, a red tongue body with a yellow coating, and a rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of diarrhea with fever, which was caused by inappropriate purging of an exterior taiyang syndrome leading to an inward invasion of the exterior pathogens to the yangming large intestine. You Yi pointed out that “70% of the exterior pathogens invaded inward, leaving the remaining 30% in the fleshy exterior.”[19] Intense heat in the large intestine makes it incapable to conduct and transmit, causing diarrhea with fever, smelly, foul, thick, and sticky stool, and a burning sensation in anus. Since there is an interior-exterior relationship between the lung and large intestine, the heat in the large intestine steams up to the lung to cause panting, and to the fleshy exterior where it steams to cause sweating. Intense heat damages the fluids, which produces a vexing heat, suppressed sensation in the chest, thirst, and scant dark urine. A red tongue with a yellow coating and a rapid pulse are signs of intense interior heat. The characteristic features of this pattern’s pathogenesis is the residual exterior pathogens, intense heat in the large intestine, failure of the large intestine to conduct and transmit, and the heat steaming the lung and fleshy exterior. Therefore, the therapeutic method is to eliminate the residual exterior pathogens from the fleshy exterior, and clear the intense interior heat from the large intestine.

Formula Actions Releases the exterior and clears the interior.

Formula Analysis

Unique Combination Features This formula combines the acrid-cool, scattering medicinals that promote ascension with bittercold, heat-clearing medicinals that promote descension. This is the method, “relieving diarrhea by clearing heat and raising yang”[20].

Formula Applications 1. Essential pattern differentiation Gé Gēn Huáng Qín Huáng Lián Tāng is a commonly used formula used to treat heat diarrhea and heat dysentery, either with an exterior pattern or without. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of diarrhea and dysentery caused by heat in the large intestine: acute gastroenteritis, chronic nonspecific ulcerative colitis, hemorrhagic enteritis, bacillary dysentery, diarrhea caused by measles, rotavirus enteritis, toxic gastroenteritis in children, amebic dysentery, ileotyphus, diabetes mellitus, and diarrhea caused by chemotherapy for malignant tumors. 4. Cautions and contraindications Do not use the formula for patients with deficiency cold patterns of diarrhea and dysentery.

Case Studies Epidemic type B encephalitis Huang, a 3-year-old male, suffering from epidemic type B encephalitis, had his initial visit on August 20th, 1958. When the child entered the inpatient department of the hospital, his temperature was 40°C, and he had symptoms of sweating and thirst, red complexion and dry lips, vomiting, a moist yellow tongue coating, unformed stool twice a day, and a rapid pulse with the right pulse larger than the left. The pattern was diagnosed as an

invasion of summerheat into the yangming qi level. The formula prescribed was a modified Bái Hŭ Tāng, a formula with large doses of acrid-cool medicinals. The formula was composed of shí gāo 45 g, zhī mŭ 6 g, shān yào 9 g, lián qiào 9 g, jīng mĭ 9 g, and zhì gān căo 3 g. On the second visit, August 20th, the patient showed symptoms of fever (40.5°C), a greasy yellow tongue coating, and unformed stool three times a day. The dose of shí gāo was increased to 60 g in the formula. In the afternoon, the temperature increased to 40.9°C. Rén shēn was then added to the formula; but, the fever and diarrhea did not clear. By the third visit on August 22nd, after ingesting large doses of Bái Hŭ Tāng for two days, his condition was worse with symptoms of fever, unformed stool four times a day, fright with fear of sounds, rough breathing, nausea, and vomiting. The symptoms of sweating, thirst, fever, yellow coating, and the large rapid pulse were signs of a Bái Hŭ Tāng pattern. But, why did the condition worsen after the formula was taken? All of a sudden, the doctor found the reason. The rapid cùn pulse of the left hand and symptoms such as a red complexion with fever, and sweating with panting indicated that there were pathogens located in the fleshy exterior. The moist yellow tongue coating, nausea, vomiting, and unformed stool with increased frequency indicated an accumulation of summerheat-dampness in the spleen and stomach. It was a pattern of diarrhea with fever. Bái Hŭ Tāng was not an appropriate formula for this patient, since it had no effect on the pathogens in the fleshy exterior and it included shí gāo and zhī mŭ, which are moist-cool medicinals that enhance dampness. No wonder the fever and unformed stool became worse after the formula was taken. The appropriate formula for diarrhea with fever is Gé Gēn Huáng Qín Huáng Lián Tāng, which is composed of gé gēn 12 g, huáng qín 9 g, huáng lián 1.5 g, and gān căo 3 g. After ingesting one dose of the formula, the temperature decreased to 39.4°C. After ingesting another

two doses of the formula, the temperature was decreased to 38.8°C, the stool formed, and the nausea and vomiting stopped. The patient recovered and returned home soon after.1 Comments: The patient showed symptoms of sweating, thirst, fever, yellow coating, and a large rapid pulse, which are signs of a Bái Hŭ Tāng pattern. However, the condition was unexpectedly worse after taking Bái Hŭ Tāng. Later, the doctor discovered that there were pathogens in the fleshy exterior, indicated by the rapid cùn pulse of the left hand, and symptoms such as a red complexion, fever, and sweating with panting. After Gé gēn Huáng Qín Huáng Lián Tāng was taken, the condition improved remarkably. This case revealed the importance of pattern differentiation; just a small error in diagnosis turned the treatment efficacy in a direction far removed than what was expected by the doctor. 1 China Academy of Traditional Chinese Medicine. Collection of Yue Mei-zhong’s Case Records 岳美中医案集. Beijing: People’s Medical Publishing House; 1978.

Sháo Yào Tāng 芍药汤Peony Decoction Source Text Collection of Writings on the Mechanism of Disease, Suitability of Qi, and the Safeguarding of Life as Discussed in the ‘Basic Questions’ (Sù Wèn Bìng Jī Qì Yí Băo Mìng Jí, 素问病机⽓宜保命集)

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. Decoct one dose of the formula (0.5 liang) with 2 zhan of water, and boil it until the volume shrinks to 1 zhan. Take the decoction warm after a meal. (Modern use: use water to decoct the medicinals.)

Formula Indications

This formula is indicated for damp-heat dysentery. The symptoms are dysentery with stool containing pus and blood, abdominal pain, abdominal urgency with rectal heaviness, burning sensation in the anus, scant dark urine, a greasy yellow tongue coating, and a wiry rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of dysentery caused by an accumulation and obstruction of damp-heat in the large intestine and qi-blood disharmony. Damp-heat steams and burns the large intestine, the large intestine fails to conduct and transmit, the qi and blood accumulate and obstruct, and the blood vessels in the large intestine become damaged, which lead to dysentery with stool containing pus and blood. Since the large intestine is obstructed, the bowel qi fails to descend and there is abdominal pain and abdominal urgency with rectal heaviness. The burning sensation in the anus, scanty dark urine, greasy yellow tongue coating, and wiry, rapid pulse are signs of the internal accumulation of damp-heat. The characteristic feature of this pattern’s pathogenesis is the accumulation and obstruction of damp-heat and qi-blood disharmony in the large intestine. The three major symptoms are abdominal pain, abdominal urgency with rectal heaviness, and dysentery with stool containing pus and blood. Given the pathogenesis and major symptoms of the pattern, the therapeutic method, as recorded in Collection of Writings on the Mechanism of Disease, Suitability of Qi, and the Safeguarding of Life as Discussed in the ‘Basic Questions’ (Sù Wèn Bìng Jī Qì Yí Băo Mìng Jí, 素问病机⽓宜保命集), is to “invigorate the blood to relieve stool with pus and blood, and moving qi to relieve abdominal urgency with rectal heaviness”[21]. Therefore, the therapeutic method is to invigorate the blood, move qi, clear heat, and dry dampness as the principle focus, and guide out food stagnation as the supplementary focus.

Formula Actions Clears heat in the large intestine, dries dampness, invigorates the blood, and moves qi.

Formula Analysis

Unique Combination Features This formula has two features. First, it invigorates the blood and moves qi, and treats the flowing by promoting its flow. Second, it uses both cold and hot medicinals, but primarily treats heat with cold.

Formula Applications 1. Essential pattern differentiation Sháo yào Tāng is a commonly used formula used for treating dysentery caused by damp-heat in the large intestine, and qi and blood disharmony. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of damp-heat in the large intestine, and qi and blood disharmony: bacillary dysentery, amebic dysentery, allergic colitis, and chordapsus. 4. Cautions and contraindications

Do not use the formula for patients with dysentery coupled with an exterior pattern and deficiency cold dysentery.

Associated Formulas Huáng Qín Tāng (Scutellaria Decoction, 黄芩汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat, arrests diarrhea, harmonizes the center, and relieves pain. [Applicable Patterns] Heat diarrhea and heat dysentery. Symptoms include: fever, bitter taste in the mouth, abdominal pain, diarrhea, a red tongue body with a yellow coating, and a rapid pulse.

Case Studies Chronic colitis Li, a 33-year-old male, had initial visit on June 10th, 1984. For the last year, he had suffered with bloody stools. The frequency of the bloody stools

had gradually increased to over ten times a day and it did not improve after receiving treatment in both an outpatient department and an inpatient department. On June of 1984, he was diagnosed with chronic colitis according to the findings of a sigmoscope examination. Because he had no improvement in his condition, the patient visited doctor Zhang for a consultation. On the first visit, he had symptoms of diarrhea, soft pasty stool containing mucus and blood three to four times a day, a sensation of incomplete defecation, smelly foul stool, dull colicky pain in the left lower quadrant, hyperactive bowel sounds, abdominal urgency with rectal heaviness, pain-relief following defecation, dizziness, poor digestion, listlessness, yellow complexion, thirst, scant yellow urine, a pale tongue with a greasy coating at the root of the tongue, and a slippery, thready pulse. The pattern was identified as an accumulation of damp-heat and visceral toxins causing bloody stool. The therapeutic method was to clear heat, remove dampness, regulate qi, and stanch bleeding. The formula prescribed was a modified Sháo Yào Tāng composed of bái sháo 15 g, huáng lián 9 g, huáng qín 9 g, ròu guì 6 g, dāng guī 10 g, dà huáng 10 g, mù xiāng 8 g, gān căo 6 g, bái tóu wēng 20 g, and mă chĭ xiàn 30 g. After ingesting two doses of the formula, the frequency of diarrhea increased, but with no other complaint. Therefore, dà huáng was removed from the formula, and shān yào 20 g was added into the formula to fortify the spleen and remove dampness. After another thirty doses of the formula, the patient fully recovered without any recurrence in the following half a year.1 Comments: Sháo Yào Tāng clears heat, resolves toxins, regulates qi, and stanches bleeding. Huáng lián, huáng qín, and dà huáng were used to clear heat. Dà huáng was used to guide out food stagnation. Ròu guì was used to warm yang in order to promote defecation. Sháo yào and gān căo were used to relax tension and relieve pain. Mù xiāng and bīng láng were

used to regulate and free the movement of qi. Dāng guī and sháo yào were used to harmonize ying and stanch bleeding. Although the number of medicinals in Sháo Yào Tāng is few, the formula achieved a good effect because all the medicinals targeted the pathomechanism of damp-heat stagnation.

Bái Tóu Wēng Tāng ⽩头翁汤Pulsatilla Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration 1 Zhang Bo-li. Sháo Yào Tāng Treating Bloody Stool芍药汤治疗脏毒便⾎. Journal of Sichuan Traditional Medicine. 1985; 8: 40.

Decoct the medicinals with 7 sheng (1400 ml) of water, and boil it until the volume reduces to about 2 sheng (400 ml). Filter the decoction and then take 1 sheng (200 ml) of the decoction warm. If recovery is not achieved with the first sheng (200 ml), then the other 1 sheng (200 ml) should be taken. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for heat toxin bloody dysentery. The symptoms are stools with pus and fresh blood, abdominal pain, abdominal urgency with rectal heaviness, burning sensation in the anus, thirst with a desire to drink, a red tongue with yellow coating, and a slippery, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of accumulation and obstruction of damp-heat and epidemic toxins in the large intestine with invasion of heat into the blood level. Damp-heat and epidemic toxins steam the large intestine and burn the adjacent blood vessels, which lead to stools that contain pus and fresh blood. Damp-heat distresses the large intestine and produces a burning sensation in the anus. The movement of qi becomes obstructed, which causes abdominal pain and abdominal urgency with rectal heaviness. Heat toxin consumes fluids and causes thirst. A red tongue with a yellow coating and a slippery, rapid pulse are signs of an intense heat toxin. The cause of the pattern is damp-heat and epidemic toxins, and the location of disease is the large intestine and the blood level. Therefore, the therapeutic method is to clear heat, dry dampness, cool blood, and resolve toxins.

Formula Actions Clears heat, resolves toxins, cools blood, and arrests dysentery.

Formula Analysis

Unique Combination Features

This primary function of this formula is to clear heat and resolve toxins with bitter-cold medicinals. The supplementary functions are to cool blood and astringe the intestines. Essentially, the formula clears heat, resolves toxins, cools blood, and arrests dysentery.

Formula Applications 1. Essential pattern differentiation Bái Tóu Wēng Tāng is a common formula used to treat heat toxin bloody dysentery. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of intense damp-heat toxins: acute bacillary dysentery, amebic dysentery, and chronic nonspecific ulcerative colitis. 4. Cautions and contraindications

Do not use this formula for patients with prolonged deficiency-cold of the spleen and stomach.

Comparison & Contrast Sháo Yào Tāng vs. Bái Tóu Wēng Tāng

Case Studies Diarrhea Huang, a 7-month-old female, suffered from diarrhea for one month. It was reported on her initial visit, that for the previous month she had diarrhea so many times a day that it was uncountable. The patient was diagnosed with enteritis, and her condition improved after taking Western medications

including smectite powder, multivitamins, and live combined Bacillus subtilis and Enterococcus aecium granules. When she was taken to the clinic for the consultation, she had smelly, frothy, watery, yellow stool with mucus two to four times a day, scant dark urine, cracked lips that bled, poor digestion, occasional spitting up of milk, a red tongue with a greasy white coating, and purple finger venules. This was a case of pediatric diarrhea caused by an accumulation of damp-heat in the large intestine. Children have delicate zang-fu organs, and in her case, an irregular diet damaged the spleen and stomach. The spleen then failed to transport nutrients, which generated interior dampness. Stagnant, enduring interior dampness transformed into heat, which obstructed the middle jiao and led to the failure of the intestine to separate the clear and the turbid. Abnormal ascending and descending of the qi produced the frothy watery stool with mucus. The damp-heat combined with food accumulation, which caused the stool to smell with a fishy odor and the urine to become scant and dark. The red tongue with greasy white coating and purple finger venules were signs of an accumulation of damp-heat in the middle jiao. The therapeutic methods used were to fortify the spleen, drain dampness, clear heat, and arrest diarrhea. The formula prescribed was a modified Bái Tóu Wēng Tāng composed of bái tóu wēng 10 g, qín pí 9 g, huáng qín 6 g, huáng lián 3 g, shú dà huáng 1.5 g, bái dòu kòu 15 g, guăng mù xiāng 3 g, jīng jiè (dry-fried) 6 g, dà fù pí 10 g, bīng láng 3 g, chuān mù tōng 9 g, chē qián căo 30 g, and mă chĭ xiàn 30 g. Two doses. In addition, the following formula was decocted and applied onto the lips of the patient. The prescription was composed of mài mén dōng 10 g, shí hú 10 g, zhī mŭ 15 g, and gān căo 3 g. Decoct one dose and spread the decoction onto the lips of the patient. On the second visit, the cracked lips were remarkably relieved, and the patient had unformed thin yellow stools two to three times a day, poor

digestion, a red tongue with a thin white coating, and a green-colored “wind pass” region of the finger venules. The pattern was an accumulation of dampheat in the large intestine. The formula was then changed to a formula designed by the physician called Jiàn Wèi Yùn Pí Tāng (Stomach-Fortifying and Spleen-Activating Decotion, 健胃运脾汤) for tonifying the spleen, draining dampness, clearing heat, and arresting diarrhea. The prescription was composed of zĭ sū gĕng 9 g, chuān huò xiāng 6 g, cāng zhú 3 g, căo guŏ 10 g, bīng láng 3 g, dà fù pí 10 g, shān zhā 6 g, shén qū 6 g, gŭ yá (dryfried) 15 g, mài yá (dry-fried) 15 g, bái dòu kòu 15 g, chuān huáng lián 1 g, huáng qín 6 g, mù tōng 9 g, and chē qián căo 30 g. Two doses. After ingesting two doses of the formula, the patient was fully recovered.1 Comments: “Diarrhea will not exist without dampness.” This case was caused by damp-heat obstructing the movement of qi, the failure of spleen to transport nutrients, and abnormal ascending and descending of qi. Therefore, Bái Tóu Wēng Tāng with additional aromatic dampness-removing medicinals, qi-regulating medicinals, and spleen-activating medicinals was initially given to the patient. After the condition improved, the Jiàn Wèi Yùn Pí Tāng was given to the patient to prevent damage to the spleen and stomach by the cool-cold medicinals, since the child had prolonged deficiency of the spleen, stomach, and original qi. The therapeutic method was to tonify the spleen, drain dampness, clear heat, and arrest diarrhea. 1 Sun Guang-rong, Yang Long-hui, Ma Jing. Collection of Typical Case Records of Time-honored Famous Contemporary Physicians: Pediatrics 当代名⽼中医典型医案集-⼉科分册. Beijing: People's Medical Publishing House; 2009.

Section 5 Heat-Clearing Formulas that Clear Deficiency Heat Heat-clearing formulas that clear deficiency heat are applied to conditions that have developed into the later stage of warm disease. In this stage the fluids are damaged and residual heat is retained in the yin level of the lower jiao, which cause night fever that abates at dawn and fever that abates without sweating. In addition, they may be applied to patterns of deficiency-heat caused by yin deficiency of the liver and kidney and deficiency-heat harassing the interior, which manifest as steaming bone fever and prolonged fever, as well as patterns of yin deficiency and fire harassment, which manifest as fever with night sweating. Commonly used medicinals found in these formulas are biē jiă, zhī mŭ, and shēng dì for nourishing yin and clearing heat, and qīng hāo, qín jiāo, and yín chái hú for clearing heat retention. For patients with intense deficiency-heat, bitter-cold huáng băi and huáng qín are added to clear fire. For patients with qi deficiency, huáng qí and shān yào are added to boost qi. For patients with blood deficiency, dāng guī and shú dì huáng are added to supplement the blood. Qīng Hāo Biē Jiă Tāng, Qīng Gŭ Săn, and Dāng Guī Liù Huáng Tāng are representative formulas.

Qīng Hāo Biē Jiă Tāng 青蒿鳖甲汤Sweet Wormwood and Turtle Shell Decoction Source Text

Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Decoct one dose of the formula with 5 cups of water, and boil it until the volume reduces to 2 cups. Take one dose, two times per day. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for patterns where yin has been damaged and these are latent pathogens. The symptoms are night fever that abates at dawn, fever that abates without sweating, a red tongue body with a scanty coating, and a thready, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by damage to the yin in the later stage of a warm disease, where there is also latent residual heat in the yin level. The wei yang of the human body runs in the exterior during the daytime and goes into the interior at night. Since latent heat has become retained in the yin level, when wei yang moves into the yin level during the night, it adds to the residual

heat that is latent in the yin level. There becomes too much yang for the yin to balance, which causes the night fever. When wei yang moves back out of the yin level to the exterior in daytime, the fever abates at dawn. Although the fever may abate at dawn, the latent heat pathogen is still retained in the yin level unable to be released from the exterior. In addition, the residual heat damages yin over time, so there is no fluids for sweat. This results in a fever that abates without sweating. A red tongue with a scanty coating and a thready, rapid pulse are signs of yin deficiency and heat. The characteristic feature of this pattern’s pathogenesis is damage to yin with latent heat in the yin level of the lower jiao. Therefore, the therapeutic method is to nourish yin and expel pathogens.

Formula Actions Nourishes yin and vents heat.

Formula Analysis

Unique Combination Features

This formula has two features. First, it combines the yin-nourishing with the heat-clearing methods, and the heat-clearing with the heat-venting methods. Second, the formula nourishes yin without retaining pathogens, and dispelling pathogens without damaging the zheng qi.

Formula Applications 1. Essential pattern differentiation Qīng Hāo Biē Jiă Tāng is a commonly used formula used to treat yin that has been damaged along with latent pathogens in the later stage of warm disease. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows prolonged low-grade fever caused by yin deficiency and interior heat: idiopathic fever, lowgrade fever in the convalescent period of various communicable diseases, chronic pyelonephritis, nephronophthisis, and children’s summer fever. 4. Cautions and contraindications

Do not use the formula in patients where the yin deficiency is about to generate wind.

Case Studies Remittent fever Zhong, a 39-year-old male, suffered from acute myelocytic leukemia for three years. The patient achieved complete remission following chemotherapy and then accepted several consolidation chemotherapies. Six months ago, the patient had a fever following consolidation chemotherapy, and the fever lasted for over a month with a temperature between 38°C and 39°C. The condition did not improve with anti-infective therapy and symptomatic treatment so at that point he then came for a consultation with Doctor Qiu. At his visit, the patient showed symptoms of remittent fever, profuse sweating, poor appetite and digestion, fatigue, baldness, pale complexion, a pale tongue body with a thick white coating, and a wiry, thready, rapid pulse. The pattern determined was deficiency of healthy qi and latent pathogen in the yin level. The therapeutic method used was to clear and vent pathogenic heat in the yin level. The formula prescribed was a modified Qīng Hāo Biē Jiă Tāng composed of qīng hāo 15 g, biē jiă (decocted first) 15 g, mŭ dān pí 15 g, jīn yín huā 15 g, nǚ zhēn zĭ 15 g, hàn lián căo 15 g, huáng qín 12 g, sāng yè 12 g, and gān căo 6 g. After ingesting one dose of the formula, the temperature decreased remarkably. After another five doses, the patient regained a normal temperature. On the second visit, the patient was given medicinals for nourishing yin, boosting qi, and resolving toxins. In addition, Qīng Dú Piàn (Toxinsclearing Tablet) composed of shān cí gū, chóng lóu, bái huā shé shé căo, zhì dà huáng, hú huáng lián, and dà qīng yè and Yăng Zhèng Piàn (Healthy QiNourishing Tablet) composed of huáng qí, rén shēn, bŭ gŭ zhī, shú dì huáng,

huáng jīng, líng zhī, nǚ zhēn zĭ, and hàn lián căo were given to the patient for consolidation.1 1 Huang Li-ming, Hu Li-wen. Prof. Qiu He-ming Treating Blood Diseases by Using Qīng Hāo Biē Jiă Tāng 丘和明教授以青蒿鳖甲汤治疗⾎液病验案. New Journal of Traditional Chinese Medicine. 2004; 36(7): 7-8.

Comments: The common causes of fever in patients with leukemia include bacterial and viral infection due to aleucocytosis, agranulocytosis, and hypoimmunity. Bone marrow depression following chemotherapy often leads to infection and fever due to agranulocytosis. An important pathogenesis of acute leukemia is deficiency of the zheng qi, and the inward invasion of pathogenic toxins that enter the blood and damage the bone marrow. In this case, as the essence and blood of the liver and kidney were damaged from chemotherapy, externally-contracted six pathogenic factors invaded the body. Why is it that the fever was not relieved after antiinfective therapy and symptomatic treatment? It is because the pathogens invaded into the yin level due to the deficiency of the liver and kidney. Therefore, the temperature returned to normal after several doses of the modified Qīng Hāo Biē Jiă Tāng since it cleared and vented the pathogenic heat from the yin level. In the middle and later stages of chemotherapy, tonifying the healthy qi and supplementing the liver and kidney according to pattern differentiation can prevent an invasion of exterior pathogens and the inward invasion of pathogens into the yin level due to the deficiency of the zheng qi.

Qīng Gŭ Săn 清骨散Bone-Clearing Powder Source Text Standards for Diagnosis and Treatment (Zhèng Zhì Zhŭn Shéng, 证治 准绳)

Formula Ingredients

Preparation and Administration Decoct one dose of the formula with 2 zhan of water, and boil it until the volume reduces to 80%. Take the decoction after meals. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for deficiency of the liver and kidney yin, and deficiency-heat harassing the interior. The symptoms are steaming bone fever, prolonged low-grade fever, emaciation, red lips and cheeks, fatigue

and night sweat, thirst and vexation, a red tongue with a scanty coating, and a thready, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of liver and kidney yin deficiency, and deficiency-heat harassing the interior. Yin deficiency generates interior heat, and deficiencyheat steams up causing steaming bone fever, thirst and vexation, and red lips and cheeks. The deficiency-heat forces fluids to move outward, which causes night sweating. Deficient yin fails to nourish flesh and skin, causing emaciation over time; the red tongue with scanty coating and thready, rapid pulse are signs of yin deficiency and interior heat. The key of this pattern is deficiency-heat, as the deficiency-heat consumes yin, and yin deficiency enhances the power of heat. Therefore, the therapeutic method should be primarily clearing deficiency-heat, and nourishing yin as supplementary.

Formula Actions Clears deficiency-heat and relieves steaming bone fever.

Formula Analysis

Unique Combination Features This formula primarily clears and vents latent heat to treat the branch, and secondarily nourishes yin to treat the root.

Formula Applications 1. Essential pattern differentiation Qīng Gŭ Săn is a commonly used formula used to treat steaming bone fever and consumptive heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of steaming bone fever caused by yin deficiency and interior heat: tuberculosis and other chronic wasting diseases.

Associated Formulas Qín Jiāo Biē Jiă Săn (Gentian and Turtle Shell Powder, 秦艽鳖甲散) [Source] Precious Mirror of Health (Wèi Shēng Băo Jiàn, 卫⽣宝鉴) [Ingredients]

[Preparation and Administration] Grind the above medicinals into powder, use 5 qian (15 g) per dose. [Actions] Nourishes yin, nourishes blood, clears heat, and relieves steaming bone fever. [Applicable Patterns] Wind taxation caused by deficiency of yin and blood, and wind invasion inward and transforming into heat. Symptoms include: steaming

bone fever, night sweat, emaciation, red lips and cheeks, thirst, afternoon tidal fever, cough, tiredness, a red tongue body with a scanty coating, and a thready, rapid pulse.

Comparison & Contrast Qīng Hāo Biē Jiă Tāng vs. Qīng Gŭ Săn

Case Studies Fever of pulmonary tuberculosis Fu, an 18-year-old female student, suffered from a fever (39°C), night sweating, dry cough, breathlessness, and severe emaciation. She went to the inpatient department of the hospital where an X-ray radiograph indicated scattered equal-sized miliary shadows all over the lungs. The result of a blood cell count revealed Hb 9.5 g/L, RBC 3.6×1012/L, WBC 9.4×109/L, N 0.75, L 0.25, erythrocyte sedimentation rate was 79 mm/h, and acid-fast bacilli were detected through inspection of a sputum smear. The admitting diagnosis was hematogenous disseminated pulmonary tuberculosis. After her

admission into the inpatient department, the following medicines were used for over 20 days: phytomycin, rifampin, rimifon, ethambutol, and bupleuri injection. On the first visit, she showed symptoms of fever (40.5°C), night sweat, cachexia, a red tongue with a scanty coating, and a weak, thready pulse. The formula prescribed was a modified Qīng Gŭ Săn composed of dì gŭ pí 30 g, yín chái hú 12 g, hú huáng lián 10 g, māo zhuă căo 30 g, qín jiāo 10 g, biē jiă 15 g, zhī mŭ 10 g, sāng yè 10 g, tài zĭ shēn 12 g, xuán shēn 15 g, băi bù 10 g, zĭ wăn 10 g, zhè bèi mŭ 10 g, and shēng gān căo 3 g. The medicinals were decocted with water. After ingesting one dose of the formula, the temperature decreased remarkably. After another two doses, the temperature returned to normal. Another two doses were then given to achieve a full recovery. Finally, the patient no longer had a fever and cough, which allowed her to continue with the antituberculosis therapy.1 Comments: The fever associated with pulmonary tuberculosis is a sign of tuberculosis toxaemia. Alexipyretic therapy used in Western medicine makes patients sweat, which is harmful to patients with deficiency. In traditional Chinese medicine, Qīng Gŭ Săn is a representative formula for steaming bone fever and consumptive heat that clears deficiency-heat and relieves steaming bone fever. The pattern is marked by steaming bone fever, emaciation and night sweat, a red tongue body with a scanty coating, and a rapid pulse. In this case, the formula was given to nourish yin, clear heat, boost the lung, promote fluid production, remove dampness, and relieve cough. The formula had a good effect because it combined the heat-clearing and yin-nourishing methods, addressed both deficiency and excess, and targeted the pathogenesis.

Dāng Guī Liù Huáng Tāng 当归六黄汤Chinese Angelica Six Yellow Decoction Source Text Secrets from the Orchid Chamber (Lán Shì Mì Cáng, 兰室秘藏)

Formula Ingredients

Preparation and Administration 1 Wang Jin-niu, Zhang Guan-liang. Qīng Gŭ Săn Treating Fever of Pulmonary Tuberculosis 清骨 散治疗肺结核⾼热. Shanghai Journal of Traditional Chinese Medicine. 2001; 35(6): 35.

Grind the medicinals into a crude powder. Decoct one dose of the formula (5 qian/15 g) with 2 zhan of water, and boil it until the volume reduces to about 1 zhan. Take the decoction before meals. The dose should be cut in half for children. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for night sweating caused by yin deficiency and intense fire. The symptoms are night sweating with fever, red

complexion, vexation, thirst and dry lips, dry stool, dark urine, a red tongue body with a yellow coating, and a rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of night sweating caused by yin deficiency and intense fire. The phase of the heart is fire, and the phase of the kidney is water. Normally, fire and water are coordinated with each other, and the heart and kidney interact with each other in a harmonious relationship. If the kidney yin becomes deficient, the kidney water fails to coordinate with the heart fire. The fire of the heart will then intensify because of the lack of water, causing the pattern of yin deficiency and intense fire. The fire will become more intense as more yin is consumed over time. Yin will not be able to stay inside as the intense fire forces fluids to leak outward, causing night sweating with fever. Deficiencyheat flames up causing a red complexion and vexation. Yin and fluids are consumed, which leads to thirst and dry lips, dry stool, and dark urine. A red tongue with a yellow coating, and a rapid pulse are signs of interior heat. The characteristic features of the pattern are deficiency of yin and blood, intense heart fire, outward leaking of yin forced by fire, and damage to the wei qi. Therefore, the therapeutic method is to nourish yin and blood, clear heat and drain fire, and boost qi to consolidate the exterior.

Formula Actions Nourishes yin, drains fire, consolidates the exterior, and arrests sweating.

Formula Analysis

Unique Combination Features This formula has two features. First, it combines the blood and yinnourishing method with the heat-clearing and fire-draining method, and addresses both the root and the branch of the pattern. Second, the formula combines the qi-boosting to consolidate the exterior method with the yinnourishing and fire-draining method; the former is the branch and the latter is the root.

Further Clarification Why is sweet-warm huáng qí included in Dāng Guī Liù Huáng Tāng, a formula for yin deficiency with intense fire harassing the interior? While this is a pattern of yin deficiency with intense fire harassing the interior, there is frequent sweating that damages wei qi. Furthermore, since yang enters the yin level when one falls asleep, wei qi is relatively deficient during sleep. Nourishing yin and draining fire alone can not effectively arrests sweating unless a qi-boosting medicinal is added to consolidate the exterior. There is also the aspect of pairing huáng qí with other medicinals in the formula to yields further formulaic actions. When huáng qí is coupled with dāng guī, they nourish qi and blood, consolidate striae and interstices, and prevent sweating. When huáng qí, a sweet medicinal, is coupled with

huáng lián, huáng qín, and huáng băi, cold medicinals, they drain fire and prevent the bitter-cold medicinals from damaging the middle jiao. In conclusion, huáng qí in Dāng Guī Liù Huáng Tāng does not enhance damage to yin by intensifying fire. Huáng qí helps nourish yin, arrest sweating, and prevent the bitter-cold medicinals from damaging the middle jiao.

Formula Applications 1. Essential pattern differentiation Dāng Guī Liù Huáng Tāng is a commonly used formula applicable for night sweating caused by yin deficiency and intense fire. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of yin deficiency and intense fire: hyperthyroidism, tuberculosis, diabetes mellitus, and menopausal syndrome. 4. Cautions and contraindications

Do not use the formula for patterns of yin deficiency without intense fire, or for patients with poor digestion and thin, unformed stools caused by deficiency of the spleen and stomach.

Case Studies Postpartum spontaneous sweating Wu, a 39-year-old female, had her initial visit on March 27th, 1980. She was often adverse to heat and her aversion to heat worsened when she was pregnant in January of 1979, and remained unchanged after she gave birth. She would drip sweat after she drank a hot drink or with gentle activity, along with aversion to wind. Before her first visit, the patient was prescribed a dozen doses of Yù Píng Fēng Săn with added lóng gŭ and mŭ lì, but the sweating did not improve. She also had vexation and fever, constipation, thirst, liking for cold drinks, a red tongue body with a thin yellow coating, and a deep thready, rapid pulse. The pattern was yin deficiency with interior excess. She was prescribed a modified Dāng Guī Liù Huáng Tāng to nourish yin, clear heat, and arrest sweating. The prescription was composed of dāng guī 10 g, shēng dì 10 g, shú dì huáng 10 g, chén pí 10 g, shēng mài yá 10 g, huáng qín 9 g, huáng lián 6 g, huáng băi 6 g, dà huáng 6 g, zhì gān căo 6 g, lóng gŭ 15 g, and mŭ lì 15 g. After ingesting two doses of the formula, the vexing heat and sweating were remarkably improved, but the aversion to wind was unchanged. Therefore, huáng qí 30 g was added to the formula. But after ingesting two doses of the formula, the condition became worse. Therefore, the original formula was given to the patient again. After four doses, the vexing heat, sweating, and aversion to heat were relieved. Another two doses of the formula and two boxes of Mài Wèi Dì Huáng Wán were given, a full recovery was achieved. The sweating did not recur in the following two months.1

Comments: Deficiency patterns are commonly seen in women after childbirth, including qi deficiency, blood deficiency, and deficiency with excess. Normally, in a case of postpartum spontaneous sweating, there is qi deficiency and insecurity of the wei at the exterior. But the patient in this case showed symptoms of aversion to heat, vexation, constipation, a red tongue, and a rapid pulse. These were signs of yin and blood deficiency with intense heat, which could not be explained with yang deficiency. Therefore, after Dāng Guī Liù Huáng Tāng was given to nourish yin and clear heat, the vexing heat and sweating were eliminated as the yin was supplemented.

Section 6 Heat-Clearing Formulas that Dispel Summerheat The heat-clearing formulas that dispel summerheat are composed of summerheat-dispelling medicinals, and are used to treat summerheat diseases. Summerheat is one of the six pathogenic factors. It has the characteristic feature of having a seasonal onset. The Yellow Emperor’s Inner Classic: Basic Questions (Huáng Dì Nèi Jīng Sù Wèn,黄帝内经素问) states, “a disease caught before the summer solstice is a warm disease, and a disease caught after the summer solstice is a summerheat disease.”[22] Essentially, any disease caused by the contraction of summerheat during the summer is recognized as a summerheat disease. The Case Records as a Guide to Clinical Practice (Lín Zhèng Zhĭ Nán Yī Àn, 临证指南医案) suggested that the therapeutic method used to treat summerheat disease is to “first use acrid-cool medicinals, follow with sweet-cold medicinals, and then finally use sweet-sour medicinals to astringe the fluids. Do not use the purgative method in patients with summerheat disease” [23]. 1 Chang Da. Dāng Guī Liù Huáng Tāng Treating Postpartum Spontaneous Sweating 当归六黄汤 治愈产后多汗症. Journal of Sichuan Traditional Medicine. 1986; (11): 39.

The heat-clearing formulas that dispel summerheat are applicable for patterns of summerheat damage during the summer. The main symptoms include fever, red complexion, vexation, scanty dark urine, a red tongue body, and a rapid or large, surging pulse. In addition, summerheat, which is apt to ascend and scatter, usually consumes qi and damages fluids. This leads to thirst, fatigue, and weakened breathing. During the summer season,

summerheat attacks the human body in tandem with the steaming dampness that rises from the ground. As a result, dampness is commonly seen in summerheat disease patterns with signs of dampness obstruction and qi stagnation, such as chest oppression, nausea, and a greasy white tongue coating. In summer, people typically like to eat cold food and drink cold beverages, and sleep with a thin blanket and use an air-conditioner or fan. However, the striae and interstices are loose and open during the summer and yang qi is apt to leak out. Therefore, summerheat disease is usually coupled with an exterior cold pattern. Heat-clearing formulas that dispel summerheat can be used for all of the patterns above. Since summerheat is a fire-heat pathogenic factor, the fundamental therapeutic method for treating it is clearing summerheat and draining heat. As a result, the heat-clearing formulas that dispel summerheat are mainly composed of acrid-cool and acrid-cold medicinals. Considering that a summerheat disease is usually coupled with exterior cold, dampness, and damaged qi and yin, the specific therapeutic method necessary for each patient matches the specific pattern that the patient is diagnosed with. For patients with only summerheat, the therapeutic method is to dispel summerheat and clear heat. For those with exterior cold, the therapeutic method is to dispel summerheat and release the exterior. For those with dampness, the therapeutic method is to dispel summerheat and drain dampness. For those with qi deficiency, the therapeutic method is to clear summerheat and boost the original qi. Representative formulas include Qīng Luò Yĭn, Xiāng Rú Săn, Liù Yī Săn, Guì Líng Gān Lù Săn, and Qīng Shŭ Yì Qì Tāng. Summerheat disease patterns tend to have a lot of different manifestations and concurrent patterns, so the therapeutic methods and formulas used to treat them vary a lot. Before choosing a heat-clearing

formula to dispel summerheat, the main pattern, concurrent pattern, and the severity of the pattern must be determined. Summerheat is usually coupled with dampness, so heat-clearing formulas that dispel summerheat often contain dampness-draining medicinals. However, the severity of summerheat and dampness must be evaluated first. Dampness can easily transform into heat in those with a preponderance of summerheat over dampness. Therefore, to avoid damaging qi and fluids, do not use warm-dry medicinals to drain dampness. Summerheat is easily obstructed by dampness in those with a preponderance of dampness over summerheat. Therefore, in order to avoid enhancing the dampness use sweet-cold medicinals with caution.

Qīng Luò Yĭn 清络饮Channel-Clearing Beverage Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Decoct one dose of the formula with two cups of water, and boil it until the volume reduces to about one cup. Take one half of the dose twice, each

day. (Modern use: use water to decoct the medicinals.)

Formula Indications This formula is indicated for mild cases of summerheat with damage to the lung channel and qi level. The symptoms are moderate thirst, moderate dizziness, the feeling of moderate distention in the head, and a light red tongue body with a thin white coating.

Analysis of Fundamental Pattern Pathogenesis In mild cases the summerheat is not severe and the damage to fluids is moderate, so the patient will manifest a low-grade fever with moderate thirst. Pathogenic summerheat harasses the brain, which causes moderate dizziness and a sense of distention in the head. A light red tongue body with a thin white coating is a sign of a mild case with moderate pathogens. For mild cases of summerheat damage, the appropriate therapeutic method is to use acrid-cool and aromatic light formulas to dispel summerheat and clear heat. There is no need to use a heavy formula for a mild case of summerheat damage.

Formula Actions Dispels summerheat and clears fire.

Formula Analysis

Unique Combination Features This formula uses six fresh materials as medicinals to dispel summerheat and clear heat. It is a light formula used to clear summerheat, vent heat, and drain dampness.

Formula Applications 1. Essential pattern differentiation Qīng Luò Yĭn is a commonly used formula used to treat mild cases of summerheat damage to the lung channel. This clinical pattern is marked by:

● moderate fever and thirst ● moderate dizziness ● thin, white tongue coating

2. Modifications

3. Cautions and contraindications This formula may be used for patients with a mild pattern of summerheat. Do not use the formula for patients with a severe exterior cold; or symptoms of a high-grade fever with severe thirst and sweating, sweating with a large scattered pulse, and panting and cough verging on desertion.

Case Studies Convulsion Chen, a 1-year-old male patient, had his initial visit on July 21th, 1980. The patient suffered from fever, cough with scanty sputum, breathlessness, listlessness, and little milk intake. His stool was normal. Since the condition did not improve with the treatment in his hometown, the patient was admitted into the hospital’s inpatient department with the diagnosis of summerheat-warmth (alveobronchiolitis). At the initial visit his temperature was measured at 39.1°C, pulse rate at 160 bpm, breathing rate at 24 times per minute. He was observed to be growing normally, had been breast-fed, had a pale complexion, sweating, breathlessness, flaring nostril, intense chest and belly movement, dry and purple lips, phlegm rale in the throat, convulsions, opisthotonos, a red tongue with a yellow coating, red-purple finger venules, and a regular cardiac rhythm. Líng Jiăo Gōu Téng Tāng was given to the patient, but the condition did not improve.

He had his second visit on the morning of July 22nd. He was unconscious and had a fever (39°C). His symptoms included a cough, breathlessness, nasal flaring, convulsions with clenched fists, opisthotonos, quivering lips and his tongue was thrust out. He had a red tongue body with a yellow coating, and his finger venules were red-purple. The pattern was diagnosed as liver heat generating wind, and the therapeutic method used was to calm the liver and extinguish wind. Líng Jiăo Gōu Téng Tāng were modified by adding xī yáng shēn, wú gōng, quán xiē, and Kàng Rè Niú Huáng Săn was given to the patient. After taking the decoction, and receiving Western medicine therapy, the condition still did not improve. At 12:00 am the temperature rose to 40°C. He was unconscious, breathless, had nasal flaring, intense convulsions, opisthotonos, a red tongue body with a yellow coating, and red-purple finger venules. The condition was worse, and the life of the patient was in danger. Doctor Zhang was asked to give a consultation. He pointed out that this was a pattern of summerheat-wind, and the convulsions could not be relieved before the summerheat was cleared. Therefore, as a first step, xióng huáng 20 g was ground into a crude powder, mixed with the egg whites of one or two eggs, and applied onto the chest and abdomen to clear heat, resolve toxins, and vent pathogens out of the body. Second, the patient was laid on a bedding of fresh hé yè (on the floor) for clearing summerheat. Finally, Qīng Luò Yĭn was given to the patient. The prescription was composed of hé yè (fresh) 6 g, biăn dòu huā 6 g, zhú yè (fresh) 6 g, jīn yín huā 6 g, sī guā luò 6 g, xī guā pí (fresh) 20 g. He was given one dose, decocted in water. Along with the formula, the patient was given only oxygen and supportive therapy. After ingesting one dose of the formula, the temperature gradually decreased with a remarkable decrease of the convulsions.

On July 23rd, he had his third visit. At that time he had a fever (38.2°C), but was conscious. He had stable breathing, flexible eye movement, frequent tongue thrust, minor onsets of convulsions with longer intervals, a red tongue body with a dry yellow coating, and red-purple finger venules. Doctor Zhang pointed out that the pattern had changed to summerheat with fluid damage. Oxygen inhalation was stopped, and the formula was given to the patient one dose in the daytime and one dose at night. Supportive therapy was unchanged. His fourth visit was on July 24rd. The convulsions and tongue thrusting were relieved, and the child could fall asleep. He had a low-grade fever and vexation, but with vigor and stable breathing. The condition had improved remarkably. Qīng Shŭ Yì Qì Tāng was then given to achieve a full recovery. The prescription was composed of rén shēn 6 g, zhī mŭ 6 g, shēng gān căo 8 g, zhú yè 8 g, mài dōng 6 g, shí hú 10 g, hé yè 6 g, and xī guā pí 20 g.1 Comments: This is a case of summerheat-wind. Initially, Líng Jiăo Gōu Téng Tāng with wú gōng and quán xiē was given, along with antibiotics, cardio tonic agents, and therapies to relieve acid poisoning and convulsions. When the condition worsened, doctor Zhang was invited to give a consultation. When he used Qīng Luò Yĭn, the other doctors were confused. However the condition remarkably improved after only one dose of the formula, and the patient almost fully recovered after three doses of the formula. Qīng Luò Yĭn was then used in another two cases of summerheatwind with good effect. Doctor Zhang then explained the reason. The unconsciousness and convulsions in the pattern of summerheat-wind are caused by intense summerheat. As a yang pathogen, summerheat has the characteristic feature of an acute onset and rapid transformation. Intense summerheat generates internal wind and causes convulsions. Líng Jiăo Gōu Téng Tāng with wú gōng and quán xiē was not effective for the patient,

because the heavy formula obstructed the pathogens. In this case, the summerheat pathogens affecting the upper jiao aggressively moved inward and obstructed the qi level, causing cough, phlegm rale, breathlessness, and nasal flaring. The pathogens were then reverse-transmitted to the pericardium, which led to unconsciousness. The intense summerheat generated wind, which caused convulsions and opisthotonos. The key to treat this condition was to clear the summerheat. According to the therapeutic principle of “expelling excess with a light formula”[24], a coolmoist light formula was used to harmonize the lung and clear the summerheat. As the heat in the lung cleared, the cough dissipated. As the summerheat drained, the fever and convulsions were alleviated. Please note that for summerheat coupled with dampness, the therapeutic method is to dispel summerheatt and drain dampness. 1 Qiu De-ze, Zhang Shou-min. Treating Convulsions Caused by Summerheat by Using Qīng Shŭ Yì Qì Tāng 张寿民⽼中医⽤“清络饮”治⼩⼉暑风的经验. Jiangxi Journal of Traditional Chinese Medicine and Pharmacy. 1982; (4): 32.

Xiāng Rú Săn ⾹薷散Mosla Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. Decoct one dose of the formula (3 qian/9 g) with 1 zhan of water and 1 fen of Chinese wine, and boil it until the volume reduces to about 7 fen. Filter the decoction and cool it down. Take two doses of the decoction consecutively either before or after meals. (Modern use: use water and a little Chinese wine to decoct the medicinals. The dose of medicinals could be reduced in proportion to the original proportion.)

Formula Indications This formula is indicated for yin summerheat. The symptoms are aversion to cold with fever, heaviness of the head, body pain, absence of sweating, abdominal pain, vomiting and diarrhea, chest and abdominal oppression and fullness, a greasy white tongue coating, and a floating pulse.

Analysis of Fundamental Pattern Pathogenesis This formula is commonly used in patients who have exterior cold and internal dampness after taking too much cold drinks or have been exposed in a cool environment for too long during the summer. In summer people usually prefer cold drinks and staying in a cool environment, yet the striae and interstices are often loose. As a result, people are apt to contract cold and dampness. Cold-dampness constrains the exterior, the striae and interstices, and blocks the wei yang. This causes an aversion to cold with fever, absence of sweating, and a floating pulse. Cold-dampness constrains the fleshy exterior and obstructs qi and blood, causing heaviness of the head and body pain. Having too much cold food and drinks during the summer damages the spleen and stomach and inhibits qi movement, which causes chest and abdominal oppression and fullness, and abdominal pain. Dampness encumbers the spleen and stomach and causes their ascending and descending functions to become irregular. This manifests as vomiting caused by the ascending counterflow stomach qi, and diarrhea caused by dampness pouring down to the large intestine. The greasy white tongue coating is a sign of cold-dampness. The therapeutic method is to release cold-dampness from the fleshy exterior, and drain the dampness encumbering the spleen and stomach.

Formula Actions Dispels summerheat, releases exterior, removes dampness, and harmonizes the center.

Formula Analysis

Unique Combination Features This formula treats patterns with simultaneous exterior and interior pathology. It combines the supplementing method with the qi-moving method, and primarily dispels summerheat, releases the exterior, and drains dampness.

Formula Applications 1. Essential pattern differentiation Xiāng Rú Săn is a common formula used to treat patients who have exterior cold and internal dampness after taking too much cold drinks or have been exposed to a cool environment for too long during the summer. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of wind-cold-dampness contraction: summer colds and acute gastroenteritis. 4. Cautions and contraindications Do not use the formula for patients with exterior deficiency and sweating, fever and sweating of summerheat-strike, and vexation with thirst.

Associated Formulas Xīn Jiā Xiāng Rú Yĭn (Newly-Supplemented Mosla Beverage, 新加⾹ 薷饮) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction.

[Actions] Dispels summerheat, releases exterior, clears heat, and removes dampness. [Applicable Patterns] Summerheat coupled with dampness and cold contraction. Symptoms include: fever with headache, aversion to cold without sweating, thirst and red complexion, chest oppression, a greasy white tongue coating, and a floating rapid pulse. Both Xiāng Rú Săn and Xīn Jiā Xiāng Rú Yĭn are applicable for dispelling summerheat. They both include acrid-warm medicinals such as xiāng rú and hòu pò to dispel summerheat, release exterior, scatter cold, and remove dampness. Xiāng Rú Săn, which includes many warm medicinals, is good at scattering cold and removing dampness. It is mainly indicated for cold-damp contraction during the summer. Xīn Jiā Xiāng Rú Yĭn contains cool medicinals such as jīn yín huā, bái biăn dòu huā (fresh), and lián qiào so it is thereby used to clear summerheat. It is mainly indicated for cold contraction and summerheat-dampness during the summer, which is marked by an aversion to cold without sweating, thirst and red complexion, and a rapid pulse. The two formulas should be clearly differentiated from each other.

Case Studies Fever Chen, a 47-year-old male, suffered from a high-grade fever and shivering for 48 days before his initial visit on November 12th, 1988. The patient went on a business trip during October in 1988 and had washed his

hair with cold water at the hotel. On October 15th, he began shivering and developed a high-grade fever (40°C). He felt he needed to be covered by a heavy blanket, and after two hours the fever cleared after he broke a sweat, and everything went back to normal. Since that episode, the condition recurred between 2 pm and 3 pm every afternoon. Occasionally, the highgrade fever occurred at night for four to five hours, and then disappears automatically without any treatment. The diagnosis remained unclear even after several physical and laboratory examinations were performed, and the condition did not improve after taking moroxydine hydrochloride and aspirin. The patient came to the hospital once his business trip was finished. Malaria and typhoid fever were suspected, but there was no evidence of it even after repeated blood tests. Xiăo Chái Hú Tāng and Gǎn Mào Tōng were given to the patient, but the condition still did not improve. On November 12th, the patient was admitted to the inpatient department of the hospital, and accepted several laboratory examinations without positive results. After several Western medicine treatments, the patient still had shivering, highgrade fever, and fever abatement after sweating; coupled with fatigue and moderate dizziness and headaches as his temperature rose. On December 1st, the Western medicine therapies were stopped, and a Chinese medicine practitioner was invited to give a consultation. On the first visit, the patient was shivering, had a high-grade fever and preferred to be covered by a heavy blanket. His fever would abate after sweating, his appetite, digestion, urination, and defecation were all normal, and he had a red tongue with a greasy thick yellow coating, and a soggy, rapid pulse. The pattern was latent summerheat, a disease of both wei and qi caused by the latent summerheatdampness stirred by the recent contraction of wind-cold. Therefore, the therapeutic method was to release the exterior with acridwarm medicinals, clear summerheat, and drain dampness. The formula prescribed was a modified Xiāng Rú Săn composed of xiāng rú 15 g, biăn

dòu 15 g, hòu pò 10 g, huò xiāng 15 g, pèi lán 15 g, zĭ sū yè 10 g, chuān huáng lián 5 g, dà qīng yè 20 g, huá shí 60 g, jīn yín huā 20 g, chén pí 5 g, and fú líng 30 g. (The formula was decocted twice and one dose was taken two times each day.) The first two doses had no effect on the disease because they were lacking xiāng rú in the formula. On the third day, when xiāng rú was available and added into the formula, the shivering and high-grade fever disappeared. After another two days of the decoction, the patient fully recovered and went back home without recurrence to this point.1 Comments: The manifestations of this case were paroxysmal shivering, high-grade fever, and abatement of fever after sweating, which are similar to the symptoms of typical malaria. Xiăo Chái Hú Tāng added with cháng shān and căo guŏ was given to the patient initially, but had no effect. The patient was working hard in the hot weather of mid-July, so latent summerheat invaded and remained lodged in his body, which damaged his healthy qi. With this pre-existing condition, the patient went for a business trip during October, and took a cold shower. The latent summerheatdampness was stirred by the newly contracted wind-cold-dampness, which caused a disease of both wei and qi with latent summerheat. That is why Xiăo Chái Hú Tāng was not effective. In this case, there was an interior pattern of summerheatdampness constraining the qi level, and an exterior pattern of wind-cold. Therefore, the therapeutic method was to target both the exterior and interior patterns by releasing the exterior with acrid-warm medicinals, clearing summerheat, and draining dampness. Xiāng rú, zĭ sū yè, hòu pò, and biăn dòu were used to release the exterior, dissipate cold, dispel summerheat, and drain dampness. Huò xiāng and pèi lán were used to drain dampness more strongly. Dà qīng yè, chuān huáng lián, and jīn yín huā were used to clear heat. Huá shí was used to clear summerheat and drain dampness. Xiāng rú,

the chief medicinal in the formula, scatters exterior pathogens, warms the center, and harmonizes the spleen. It is a key medicinal for patients with yang qi that is constrained after having too many cold drinks or staying in a cool environment for too long during the summer. Xiāng rú is a commonly used medicinal for patterns of cold and summerheat-dampness during the summer. In this case, the effect of Xiāng Rú Yĭn with and without xiāng rú was very different from each other, which proved the medicinal effect of xiāng rú.

Liù Yī Săn 六⼀散Six-to-One Powder Source Text Formulas from the Discussion Illuminating the Yellow Emperor’s Basic Questions (Huáng Dì Sù Wèn Xuán Míng Lùn Fāng, 黄帝素问宣明论⽅) 1 He Xiao-ping. Modified Xiāng Rú Yĭn Treating Long-Term High Fever 加味⾹薷饮治愈长期 ⾼热⼀例. Guangxi Journal of Traditional Chinese Medicine. 1989; 12(6):13.

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine powder. Mix one dose of the formula (3 qian/9 g) with water and a little honey, or mix one dose of the formula with water only. Take one dose per day in three increments. For patients who prefer cold drinks, mix one dose of the formula with fresh well water. (Modern use: grind the medicinals into fine powder. Decoct one dose of the formula (9-18 g) while wrapped, or mix it with warm water. Take two or three doses per day. The medicinals can be decocted with other formulas as well.)

Formula Indications This formula is indicated for summerheat-dampness. The symptoms are fever with vexation and thirst, inhibited urination, and diarrhea.

Analysis of Fundamental Pattern Pathogenesis This is a fundamental formula for the pattern of summerheat-dampness. The causes are exterior summerheat and interior summerheat-dampness. Summerheat is a yang pathogen and communicates with the heart, which causes fever and vexation. Summerheat damages the fluids, causing thirst. Summerheat is often coupled with dampness, and internal dampness obstruction disturbs qi transformation of the bladder, which inhibits urination. Dampness pours down to the large intestine, which leads to diarrhea. Therefore, the therapeutic method is to clear summerheat and drain dampness.

Formula Actions Clears summerheat and drains dampness.

Formula Analysis

Unique Combination Features This formula clears heat without retaining dampness, and promotes urination without damaging the healthy qi.

Formula Applications 1. Essential pattern differentiation

Liù Yī Săn is a fundamental formula used for inhibited urination caused by summerheat with damp-heat. This clinical pattern is marked by:

● fever with vexation ● thirst ● inhibited urination 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of damp-heat: cystitis and urethritis. 4. Cautions and contraindications Do not use the formula for patients without damp-heat, nor for patients with yin deficiency or those who have long voiding of clear urine.

Associated Formulas Yì Yuán Săn (Original Qi-Boosting Powder, 益元散) [Source] Direct Investigation of Cold Damage (Shāng Hán Zhí Gé, 伤寒直格)

[Ingredients]

[Preparation and Administration] Grind these medicinals into powder. Take proper amount with decoction of dēng xīn căo. [Actions] Clears the heart, dispels summerheat, and calms the mind. [Applicable Patterns] Summerheat-dampness coupled with severe palpitations, sleeplessness, and profuse dreaming. Bì Yù Săn (Jasper Jade Powder, 碧⽟散) [Source] Direct Investigation of Cold Damage (Shāng Hán Zhí Gé, 伤寒直格) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears summerheat. [Applicable Patterns] Summerheat-dampness with heat constraint of the liver and gallbladder.

Jī Sū Săn ( Cock’s Waking Powder, 鸡苏散) [Source] Direct Investigation of Cold Damage (Shāng Hán Zhí Gé, 伤寒直格) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Scatters wind and dispels summerheat. [Applicable Patterns] Summerheat-dampness coupled with moderate aversion to wind-cold, headache and a distending sensation of the head, and an uncontrollable cough. All of the three formulas above dispel summerheat, clear heat, and drain dampness, and are applicable for summerheat-dampness. In addition, Yì Yuán Săn can calm the mind, Bì Yù Săn can clear the liver heat, and Jī Sū Săn can release exterior. Each formula has its own features.

Guì Líng Gān Lù Yĭn 桂苓⽢露饮Cinnamon and Poria Sweet Dew Beverage Source Text Formulas from the Discussion Illuminating the Yellow Emperor’s Basic Questions (Huáng Dì Sù Wèn Xuán Míng Lùn Fāng, 黄帝素问宣明论⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a crude powder. Mix one dose of the formula (3 qian/9 g) with warm water, fresh well water, or ginger soup (this is the best). For children, one dose of the formula is 1 qian (3 g). (Modern use: use water to decoct the medicinals. The dose of the formula can be reduced in a proportional ratio to the original doses.)

Formula Indications

This formula is indicated for summerheat-dampness. The symptoms are fever with headache, vexation and thirst, inhibited urination, cholera, vomiting, and diarrhea.

Analysis of Fundamental Pattern Pathogenesis This is a commonly used formula for severe cases of summerheatdampness. Exterior summerheat causes a fever with headache. Intense heat damages the fluids, causing vexation and thirst. Intense dampness disturbs the qi transformation of the bladder, which leads to inhibited urination. Intense summerheat and intense dampness damage the spleen and stomach causing irregular ascending and descending and failure of the clear and turbid to separate, which manifests as cholera, vomiting, and diarrhea. The therapeutic method is to clear summerheat and transform qi to promote urination.

Formula Actions Clears summerheat, resolves heat, transforms qi, and drains dampness.

Formula Analysis

Unique Combination Features In addition to several heat-clearing and dampness-draining medicinals, this formula uses acridhot ròu guì to promote the bladder qi transformation in order to drain dampness, and prevent the cool-cold medicinals from retaining pathogens.

Formula Applications 1. Essential pattern differentiation Guì Líng Gān Lù Yĭn is a commonly used formula for clearing summerheat and draining dampness. This clinical pattern is marked by:

● fever with headache ● vexation and thirst ● inhibited urination

2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of summerheat-dampness: summerheat-strike and urinary tract infection. 4. Cautions and contraindications Guì Líng Gān Lù Yĭn is a heavy formula for clearing summerheat and draining dampness, and is used mainly in severe cases of summerheatdampness. Do not use the formula in mild cases of summerheat damage, or patients with severe damage of qi and fluids after too much sweating and diarrhea.

Case Studies Fever Gao, a 17-year-old male, had his first visit on July 12th, 2006. In early June of 2006, he developed an idiopathic fever. His temperature was

between 37.5°C and 38.5°C, which was mild in the morning and severe in the afternoon. The patient spent half a month in an inpatient department of a hospital without any positive diagnostic examination results, and without any improvement from neither antibiotic therapy nor traditional Chinese medicine. Due to his condition, he had to suspend his schooling until his condition improved. On the first visit, the patient had a fever (38.5°C), thirst, fatigue, poor appetite, dark urine, thin unformed stool two or three times a day, a red tongue with a greasy white coating, and a soggy, rapid pulse. Given the symptoms and the onset of the summer season, the pattern was diagnosed as summerheat-dampness. Modified Sān Rén Tāng combined with Huò Pò Xià Líng Tāng was given to the patient. Half a month later, the stool and appetite returned to normal, but the fever remained unchanged. The formula was then changed to a modified Guì Líng Gān Lù Yĭn. The prescription was composed of fú líng 15 g, zé xiè 15 g, zhū líng 15 g, gān căo 6 g, bái zhú 12 g, ròu guì 3 g, shí gāo 30 g, huá shí 30 g, hán shuĭ shí 30 g, lú gēn 30 g, pèi lán 10 g, and qīng hāo 10 g. The medicinals were then decocted with water, and one dose was taken each day. After ingesting the formula for ten days, the fever and all of the other symptoms disappeared and the patient was able to go back to school. 1 Comments: The patient suffered from a fever for a long time, without any positive diagnostic examination results, no clear reason, and no effect from neither Western medicine nor traditional Chinese medicine. According to the characteristic features of symptoms and the onset season, the pattern was summerheat-dampness. But modified Sān Rén Tāng coupled with Huò Pò Xià Líng Tāng was not effective, because it contained aromatic medicinals to remove dampness, but could not effectively clear summerheat. Since the modified Guì Líng Gān Lù Yĭn could clear summerheat, transform

qi, and drain dampness, it effectively targeted the disease mechanism causing the pattern. The summerheat-dampness was resolved, and finally the enduring fever was cured. 1 Zhang Kou-qi. Two Successful Cases by Using Guì Líng Gān Lù Yĭn 桂苓⽢露饮治验⼆则. Shanxi Journal of Traditional Chinese Medicine. 2008; 24(3): 40-41.

Qīng Shŭ Yì Qì Tāng 清暑益⽓汤SummerheatClearing Qi-Boosting Decoction Source Text Warp and Woof of Warm-Heat Diseases (Wēn Rè Jīng Wĕi, 温热经纬)

Formula Ingredients

Preparation and Administration Use water to decoct the medicinals.

Formula Indications This formula is indicated for patterns of summerheat with damage to both qi and fluids. The symptoms are fever with profuse sweating, thirst and vexation, scanty dark urine, fatigue and weak breathing, listlessness, and a deficient, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis

This is a commonly used formula for summerheat damaging both qi and fluids. The cause of the pattern is inward invasion of summerheat-heat, causing the consumption of qi and fluids. Since summerheat is a yang pathogen, and communicates with the heart, when summerheat-heat attacks the human body it causes a fever. Pathogenic summerheat-heat harasses the heart and causes vexation. Scattering and ascending summerheat loosens and opens the striae and interstices, which leads to profuse sweating. Heat damages the fluids and leads to thirst and scanty dark urine. Summerheat easily consumes qi, which causes fatigue, weak breathing, listlessness, and a deficient pulse. Wang Shi-xiong said, “since summerheat damages the qi and fluids, the method of clearing summerheat-heat and boosting the original qi has a good remedial effect to this pattern. ”[25] (Warp and Woof of WarmHeat Diseases, Wēn Rè Jīng Wĕi, 温热经纬) Therefore, the therapeutic method for this pattern is to combine the summerheatdispelling and heatclearing method with the qi-boosting and fluids-generating method.

Formula Actions Clears summerheat, boosts qi, nourishes yin, and generates fluids.

Formula Analysis

Unique Combination Features This formula combines the summerheat-clearing and heat-draining method with the qi-boosting and yin-nourishing methods. It dispels pathogens without damaging the healthy qi, and reinforcing healthy qi without retaining pathogens.

Formula Applications 1. Essential pattern differentiation Qīng Shŭ Yì Qì Tāng is a commonly used formula used to treat summerheat damage during the summer with damage to both qi and yin. This clinical pattern is marked by:

● fatigue and weak breathing ● thirst and profuse sweating ● deficient, rapid pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of summerheat-strike and heat damage to both qi and fluids: summerheat damage during the summer, summer fever in children, flare up of bronchial asthma during summer, pneumonia, and the convalescence stage of other acute infectious diseases. 4. Cautions and contraindications As there are nourishing and greasy medicinals in the formula, do not use the formula for summerheat disease with dampness.

Summary There are twenty-one formulas and eight associated formulas that clear heat in this chapter. They can be classified into six categories according to their function.

● heat-clearing formulas that clear heat from the qi level ● heat-clearing formulas that clear the ying level and cool blood ● heat-clearing formulas that resolve toxins ● heat-clearing formulas that clear heat from the zang-fu organs ● heat-clearing formulas that clear deficiency heat

● heat-clearing formulas that clear summerheat 1. Heat-clearing formulas that clear heat from the qi level These formulas are applicable for patterns of heat in the qi level. Bái Hŭ Tāng is indicated for yangming stomach heat with damaged fluids. In this heavy heat-clearing formula, shí gāo and zhī mŭ are mutually reinforced and are coupled with jīng mĭ and gān căo to clear heat and generate fluids. Zhú Yè Shí Gāo Tāng is used for residual heat, damage to both qi and fluids, and disharmony of stomach qi in the later stages of febrile diseases. Zhī mŭ is not included in this formula; instead, zhú yè and shí gāo are used to clear and vent residual heat, rén shēn and mài dōng are used to boost qi and nourish yin, and bàn xià is used to harmonize the stomach and direct counterflow downward. The heat-clearing action of Zhú Yè Shí Gāo Tāng is not as strong as that of Bái Hŭ Tāng. However, it is a formula that both clears heat and supplements, and effectively boosts qi, nourishes yin, and harmonizes the stomach. Liáng Gé Săn is applicable for heat burning in the chest and diaphragm. It combines medicinals that clear and vent heat constraint with medicinals that dredge the bowels and discharge heat. It dissipates heat constraint from the chest and diaphragm by clearing heat from the upper and discharging heat from the lower. 2. Heat-clearing formulas that clear the ying level and cool blood Qīng Yíng Tāng and Xī Jiăo Dì Huáng Tāng are commonly used formulas that clear the ying level and cool blood. They both use xī jiăo (substituted by shuĭ niú jiăo in the modern era) and shēng dì to clear the heat in the ying level and blood level. Qīng Yíng Tāng is mainly indicated for heat entering the ying level (without entering the blood level), with symptoms of fever aggravated at night, vexation and sleeplessness, delirious speech at times, inconspicuous macules and papules, and a crimson colored,

dry tongue. The characteristic feature of the pattern is heat in the ying level damaging yin, harassing the heart, and attacking blood vessels. In Qīng Yíng Tāng, xuán shēn, mài dōng, zhú yè, huáng lián, and dān shēn are used to reinforce the action to clear heat, resolve toxins, and nourish yin. Jīn yín huā and lián qiào, light, heatclearing, scattering, and venting medicinals, are used to eliminate heat from the ying level by venting it through the qi level by using the method of venting heat from the ying level through the qi level. Xī Jiăo Dì Huáng Tāng is mainly indicated for heat entering the blood level, with symptoms of spitting of blood, nosebleed, bloody stool, bloody urine, purple-black macules and papules, unconsciousness, delirious speech, and a crimson-colored tongue. The characteristic features of this pattern are heat harassing the heart spirit, heat burning the blood vessels and consuming the blood, and blood amassment with static heat. In Xī Jiăo Dì Huáng Tāng, mŭ dān pí and sháo yào are used to clear heat, cool blood, invigorate blood, and dissipate stasis by using the method of cooling the blood and dissipating stasis. 3. Heat-clearing formulas that resolve toxins These formulas are used for warm epidemics, warm toxins, fire toxins, sores, and boils. Huáng Lián Jiĕ Dú Tāng is mainly indicated for intense fire toxins in the sanjiao, with no damage to the yin and fluids. Since it combines many extremely cold and extremely bitter medicinals together in order to clear the fire toxins from the sanjiao, Huáng Lián Jiĕ Dú Tāng is a formula with the function to direct repulse with bitter-cold medicinals. Pŭ Jì Xiāo Dú Yĭn is mainly indicated for swollen-head infection caused by wind-heat and epidemic toxins flaming up to the head and face. It clears heat, resolves toxins, vents heat constraint, and scatters wind. Xiān Fāng Huó Mìng Yĭn is mainly indicated for yang patterns in the initial stage of sores, abscesses, and ulcers with or without pus. Since it clears heat, resolves toxins, moves qi,

invigorates blood, dissipates masses, and disperses swelling, Xiān Fāng Huó Mìng Yĭn is called the “best remedy for sores, abscesses, and ulcers, and the first choice among formulas for external diseases”. 4. Heat-clearing formulas that clear heat from the zang-fu organs These formulas are used to clear heat from the various zang-fu organs. They vary a lot in terms of their functions and their target patterns. Dăo Chì Săn clears heart heat, promotes urination, and nourishes yin. It is mainly indicated for sores in the mouth and tongue caused by intense heat in the heart channel and heat strangury with difficult and painful urination caused by the transmission of heart heat to the small intestine. Lóng Dăn Xiè Gān Tāng discharges excessive heat from the liver and gallbladder and clears damp-heat in the lower jiao. It is mainly indicated for the flaming up of excessive fire in the liver and gallbladder and pouring downward of dampheat in the liver channel, which manifest as headache, red, swelling, and painful eyes, bitter taste in the mouth, deafness and swelling of ears, painful urination with turbid urine, smelly yellow leukorrhea, and swollen and itchy exterior genitalia. Zuŏ Jīn Wán drains liver fire, directs counterflow downward, and arrests vomiting. It is mainly indicated for liver fire invading the stomach, manifesting as burning pain in the rib-side, bitter taste in the mouth, epigastria upset, and acid swallowing. Wĕi Jīng Tāng is mainly indicated for lung abscesses that have already formed or are in the formative stages. It combines medicinals that clear heat, dissolve phlegm, and expel stasis, reflecting the abscess-resolving method used for treating lung abscesses once pus has been formed. Xiè Bái Săn is neither designed to clear excessive lung heat to treat the branch, nor nourish the lung yin in order to treat the root of the disorder. The target of the formula is to relieve coughing and panting by clearing retained lung fire. Both Qīng Wèi Săn and Yù Nǚ Jiān are commonly used formulas for treating toothaches caused by stomach

heat by clearing stomach heat. Qīng Wèi Săn is mainly indicated for toothaches, gingival atrophy and bleeding, swelling and pain in the cheeks caused by stomach fire and blood heat. This formula combines medicinals that clear stomach fire with medicinals that cool blood, scatter and rise, and resolve toxins to vent latent fire. Since it primarily clears stomach heat and nourishes the kidney yin, Yù Nǚ Jiān is mainly indicated for toothaches, gingival bleeding, vexing heat, and xiāo kĕ caused by excessive stomach heat and kidney yin deficiency. Gé Gēn Huáng Qín Huáng Lián Tāng is mainly indicated for diarrhea with fever as it releases the exterior and clears heat; it reflects the method of “relieving diarrhea through clearing heat and raising yang”. Both Sháo Yào Tāng and Bái Tóu Wēng Tāng are used for dysentery. However, Sháo Yào Tāng is mainly indicated for damp-heat dysentery which manifests as dysentery with stool containing pus and blood. It invigorates the blood, moves qi, clears heat, and dries dampness; reflecting the method of “treating the flowing by promoting its flow”. Bái Tóu Wēng Tāng clears heat, resolves toxins, and cools blood. It is mainly indicated for heat toxin bloody flux which manifests as stool with pus and fresh blood. 5. Heat-clearing formulas that clear deficiency heat Both Qīng Hāo Biē Jiă Tāng and Qīng Gŭ Săn are commonly used formulas for fever due to yin deficiency, because they can clear heat and nourish yin. Qīng Hāo Biē Jiă Tāng is mainly indicated for night fever that abates at dawn caused by damaged yin and latent pathogens in the yin level. In the formula, chief medicinals qīng hāo and biē jiă are coupled with shēng dì and zhī mŭ to nourish yin and vent pathogens. Qīng Gŭ Săn is mainly indicated for steaming bone fever caused by yin deficiency with internal heat, and is composed of several medicinals that clear deficiency heat. Dāng Guī Liù Huáng Tāng is mainly indicated for night sweating caused by yin

deficiency and intense fire, because it nourishes yin, drains fire, consolidates the exterior, and arrests sweating. 6. Heat-clearing formulas that clear summerheat Xiāng Rú Săn is commonly used for patients who have exterior cold and internal dampness after taking too much cold drinks or have been exposed to a cool environment for too long during the summer. It dissipates exterior cold and removes internal dampness constrained in the spleen and stomach. Liù Yī Săn is a fundamental formula for summerheat-dampness, and is effective at clearing summerheat and draining dampness. Guì Líng Gān Lù Yĭn is a commonly used formula for severe cases of summerheatdampness, because it clears summerheat, transforms qi, and promotes urination. Qīng Shŭ Yì Qì Tāng is indicated for the pattern of inward invasion of summerheat-heat and consumption of qi and fluids, because it clears summerheat, boosts qi, and nourishes yin.

Questions 1.Please state the indications of Zhú Yè Shí Gāo Tāng. 2.If Zhú Yè Shí Gāo Tāng is indicated for the late stage of a febrile disease, why is acrid-warm bàn xià included? 3.How do Qīng Yíng Tāng and Xī Jiăo Dì Huáng Tāng differ in composition, actions, and indications? 4.Qīng Wèi Săn and Yù Nǚ Jiān are both formulas that drain stomach fire. How do these two formulas differ in clinical applications? 5.Gé Gēn Huáng Qín Huáng Lián Tāng, Sháo Yào Tāng and Bái Tóu Wēng Tāng are all indicated for dysentery. How do these three formulas differ in composition, actions, and indications?

Endnotes: [1] 热者寒之 [2] 温者清之 [3] 以⼤寒之剂，易为清补之⽅ [4] 以泻代清 [5] 入营犹可透热转⽓ [6] ⾆⽩滑者，不可与也 [7] ⾆⽩滑，不惟热重，湿亦重矣，湿重忌柔润药 [8] 入⾎就恐耗⾎动⾎，直须凉⾎散⾎ [9] 胆⽕上升⼼营热 [10] ⽕邪极盛⽽载⾎上泛者、有⽢寒咸寒之法 [11] 借少阳为出路，舍柴胡何以枢转伏邪 [12] 疮疡之圣药，外科之⾸⽅ [13] 脓未成者即消，已成者即溃 [14] ⽔虚⽕不实 [15] ⾚者，⼼热，导⾚散主之︔淡红者，⼼虚热，⽣犀散主之 [16] 肝为刚脏 [17] 郁则⽓滞，⽓滞久则必化热 [18] 若无汗，是为外寒郁遏肺⽕，加麻黄、杏仁以发之 [19] 其邪陷于⾥者⼗之七，⽽留于表者⼗之三

[20] 清热升阳⽌利 [21] ⾏⾎则便脓⾃愈，调⽓则后重⾃除 [22] 先夏至⽇者为病温，后夏至⽇者为病暑 [23] 暑病⾸⽤⾟凉，继⽤⽢寒，终⽤⽢酸敛津，不必⽤下 [24] 轻可去实 [25] 暑伤⽓阴，以清暑热⽽益元⽓，无不应⼿取效

CHAPTER 5 Formulas that Warm the Interior Formulas that warm the interior contain interior-warming medicinals as their major components. They have the therapeutic actions to warm the interior, and assist yang to dissipate cold and free the channels. They are used for treating internal cold syndromes. The formulas in this chapter are generally called formulas that warm the interior. Interior cold patterns are mainly caused by cold pathogenic factors. The interior cold is either due to yang deficiency, or exterior cold that has penetrated into the zang-fu organs and three yin channels directly. Exterior cold and internal cold are the only two causes of interior cold patterns. The main clinical manifestations include an aversion to cold, cold limbs which respond to warmth, lying in bed curled up, pale complexion, no appetite, no thirst, clear and profuse urine, and a deep slow or moderate pulse. The treatment principle is primarily to warm the interior and expel cold. Formulas that warm the interior are categorized into three types according to the effect of the formula, the region that the formula effects, and the seriousness of the syndrome it treats.

● Formulas that warm the center and dispel cold ● Formulas that restore yang and rescue counterflow ● Formulas that warm the channels and expel cold

Pathogenic cold is a yin pathogen that easily damages yang. Therefore, formulas that warm the interior are often combined with medicinals that supplement qi in order to restore the yang. On the one hand, they usually consist of medicinals that are pungent, hot, and dry, so it is necessary to distinguish whether the cold pattern is true cold or not. It is forbidden to apply an interior-warming formula for a pattern of true heat with false cold. Caution should be exercised to prevent damaging the yin with these formulas for people who have a loss of blood or yin deficiency. On the other hand it is reasonable to add a cold or cool medicinal to the formula as a paradoxical assistant, or to take the decoction cold in order to avoid mutual repelling of cold and heat for those who have an excess yin pattern or true cold with false heat and cannot swallow the decoction. In addition, the dosage of the interior-warming formulas should be carefully considered and used flexibly, according to the patient, season, and area.

Section 1 Formulas that Warm the Center and Dispel Cold Formulas that warm the center and dispel cold are used to treat patterns of deficiency-cold in the middle jiao. The spleen and the stomach are located in the middle jiao. They govern transportation and transformation, and control ascending and descending. In a deficiency-cold pattern, the spleen and stomach fail to govern transportation and transformation or control the movement of ascending and descending. The signs and symptoms include stomachache, abdominal pain, nausea, vomiting, diarrhea, loss of appetite, lassitude of the limbs and body, cold limbs, a white slippery tongue coating, and a deep, thready or slow pulse. Formulas that warm the center and dispel

cold are often composed of center-warming and cold-expelling medicinals such as gān jiāng and wú zhū yú and spleen fortifying and qi boosting medicinals like rén shēn and bái zhú. Common formulas in this category include Lĭ Zhōng Wán, Xiăo Jiàn Zhōng Tāng, and Wú Zhū Yú Tāng.

Lĭ Zhōng Wán 理中丸Center-Regulating Pill Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration As a pill: pound and sift these four medicinals, mix with honey to make pills as big as an egg yolk (9 g). To take, break up and mix a pill with boiled water and drink when it is still warm. Take three or four doses during the day, and two at night. If the stomach is not warm after taking the pill, increase the dosage up to three or four pills. It should be noted that the therapeutic effect of the pills is less than that of a decoction. As a decoction: cut the four medicinals into pieces. Add to 8 sheng of water and boil down until 3 sheng of water remains. Take the warm decoction three times a day. Eat 1 sheng of hot porridge a little while after drinking the decoction. If the body feels hot at this point, the clothes should

be kept on. (Modern use: grind these four medicinals into fine powder, mix with honey to make pills about 9 g, take one pill each time with warm water, two or three times a day. Or use as decoction, adjust the medicinal dosages according to their original proportions.)

Formula Indications 1.Deficiency-cold of the spleen and stomach. The symptoms include chronic stomachache which can be reduced by warmth and pressure, vomiting, loose stool, distention and fullness of the stomach, poor appetite, fear of cold, cold limbs, a pale tongue with a white coating, and a deep, thin pulse or deep, slow and feeble pulse. 2.Blood loss due to spleen yang deficiency. The symptoms are bloody stool, spitting of blood, nose bleeding, and menstrual flooding and spotting with pale and thin blood. 3.Chest bì syndrome due to deficiency-cold of the spleen and stomach. Besides the obstruction of qi in the chest, other symptoms include stuffiness and fullness in the chest and stomach, qi counter-flowing to the chest, profuse saliva after the illness, or chronic infantile convulsions.

Analysis of Fundamental Pattern Pathogenesis This formula is indicated for patterns caused by deficiency-cold of the spleen and stomach. Insufficiency of center yang produces cold, yang deficiency fails to warm, and cold has the property of coagulation and stagnation so there is a fear of cold, cold limbs, and occasional abdominal pain reduced by pressure and warmth. The spleen governs transportation and transformation and controls the ascent of the clear, while the stomach governs receiving food and the descent of the turbid. However in patterns of

deficiency-cold of the spleen and stomach the ascending and descending function is damaged, so there is distention and fullness of the stomach, poor appetite, vomiting, and loose stool. All manifestations such as the pale tongue with a white, watery coating, lack of thirst, and a deep, thin or deep, slow and feeble pulse refers to deficiency-cold. The treatment is to warm the center in order to dispel cold, boost qi, and fortify the spleen.

Formula Actions Warms the center and dispels cold, boosts qi and supplements the spleen.

Formula Analysis

Continued

Unique Combination Features Based on the warming and supplementing method, this formula reinforces center yang and benefits spleen qi, and promotes the

transportation and transformation of the body. It is therefore named “centerregulating”.

Further Clarification 1. Blood loss due to yang deficiency The spleen governs the blood; however in patterns of spleen yang insufficiency, it fails to govern. The blood rising upward causes hematemesis or nosebleeds; and the blood moving downward causes bloody stools or flooding and spotting. Lĭ Zhōng Wán treats the root in order to rectify related hemorrhage problems. Clinically, gān jiāng can be replaced by páo jiāng, or other channel-warming and blood-stanching medicinals can be added to treat the branch. 2. Chest bì Lĭ Zhōng Wán can treat chest bì. It is a pattern of yang insufficiency of the middle jiao leading to yang deficiency of the upper jiao. Pathogenic cold moves upward and obstructs the qi of the chest, which causes distention and fullness of the stomach and qi counterflowing to the chest. The therapeutic method is to warm the center and dispel cold, boost qi, and fortify the spleen instead of breaking qi. This method can reinforce and complement the qi of the middle jiao in order to dispel cold, guide the qi downward, and cure the chest bì. In Essentials from the Golden Cabinet, Lĭ Zhōng Wán was used as a decoction, named Rén Shēn Tāng, to treat the chest bì. 3. Chronic infantile convulsion Congenital insufficiency, or postnatal improper childbearing, taking too much cold food or improper maintenance after severe illness damaging the yang of the spleen and stomach, causes this disease. Symptoms such as

emaciation, cold limbs, vomiting, diarrhea, mental fatigue, poor appetite, a pale tongue with white coating, and a thin, deep or slow, weak pulse belong correspond to deficiency-cold of the middle jiao; therefore this formula is effective. Clinically, add jiāng cán and chán tuì to extinguish wind and arrest convulsions in order to treat both root and branch. 4. Dosage form There are two forms of this formula: pills and decoction. As described above in “preparation and administration”, Lĭ Zhōng Wán can be made into pills. However, it is said that the therapeutic effect of the pills is not as effective as the decoction. This indicates that one should use pills for chronic conditions and decoctions for acute circumstances. After recovering from a severe illness, if one is left spitting, it is not an acute circumstance; use pills to treat. It is therefore said in Treatise on Cold Damage: “it should be warmed by pills.” Chest bì belonging to deficiency syndrome is an acute circumstance; this is why in Essentials from the Golden Cabinet the decoction is recommended. In conclusion, this formula can be used as either a pill or decoction depending on the acute or chronic state of the disease.

Formula Applications 1. Essential pattern differentiation This is a basic formula for deficiency-cold of the spleen and stomach, also known as deficiencycold of the middle jiao. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency-cold of the spleen and stomach: acute or chronic gastritis, gastric and duodenal ulcers, stomach cramps, gastroptosis, gastric dilatation, and chronic colitis. 4. Cautions and contraindications This formula is prohibited for syndromes of damp-heat accumulation in the middle jiao and spleen-stomach yin deficiency.

Associated Formulas Fù Zĭ Lĭ Zhōng Wán (Aconite Center-Regulating Pill, 附⼦理中丸) [Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Grind the above medicinals into a fine powder, and mix with honey to make pills. One liang makes 10 pills. [Actions] Warms yang and dispels cold, boosts qi, and fortifies the spleen. [Applicable Patterns] Severe deficiency-cold of the spleen and stomach, or syndrome of spleen-kidney yang deficiency, or cholera, vomiting, diarrhea, cramp and spasm. Guì Zhī Rén Shēn Tāng (Cinnamon Twig and Ginseng Decoction, 桂 枝⼈参汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Among all the five medicinals, add 9 sheng of water, decoct four of them of 5 sheng, add guì zhī and decoct again till 3 sheng left, remove the remainder, take 1 sheng of warm decoction, twice in the day time and once at night. [Actions] Warms yang and fortifies the spleen, releases the exterior, and dissipates cold.

[Applicable Patterns] Deficiency-cold of the spleen and stomach, attacked by wind-cold, aversion to cold with fever, headache, general pain, abdominal pain, diarrhea, loose stool, no thirst, a pale tongue with a white and watery coating, and a floating, weak pulse. Both Fù Zĭ Lĭ Zhōng Wán and Guì Zhī Rén Shēn Tāng are modifications based on Lĭ Zhōng Wán. Fù Zĭ Lĭ Zhōng Wán is composed of Lĭ Zhōng Wán and fù zĭ. Fù zĭ, acrid and hot in nature, has a strong effect to warm the center and dissipate cold, as well as to warm the kidney. It is used for syndromes of severe deficiency-cold of the spleen and stomach or spleen-kidney yang deficiency. Guì Zhī Rén Shēn Tāng consists of Rén Shēn Tāng and guì zhī. Guì zhī warms yang and fortifies the spleen while it simultaneously releases exterior-cold. It treats both the exterior and interior and is therefore used for deficiency-cold of the spleen and stomach accompanied by exterior wind-cold.

Case Studies 1. Diarrhea due to deficiency-cold Li, a 58-year-old male, had his initial visit on April 6th, 1965. He caught a cold three months ago and started to have diarrhea. He would defecate undigested food three or four times a day. He suffered with distention and fullness of the stomach and abdomen, which would worsen after meals, dizziness, occasional belching, a white moist tongue coating, and a thready, moderate pulse. The pattern differentiation was interior deficiency, cold fluid retention, and disharmony of ascending and descending. The treatment was to warm the center and boost qi, harmonize the stomach, and dissolve fluid retention. Lĭ Zhōng Tāng was prescribed with the addition of dăng shēn 3

qian, páo jiāng 2 qian, zhì gān căo 2 qian, cāng zhú 3 qian, chén pí 5 qian, and biăn dòu (dry-fried) 3 qian. The diarrhea mostly ceased after taking six doses, and the distention and fullness of the stomach and abdomen also decreased. The disease was cured after taking another six doses.1 Comments: This diarrhea is typically caused by interior deficiency and cold fluid retention. Lĭ Zhōng Tāng was used to warm the center to supplement deficiency. Chén pí was used to rectify qi, dry dampness and harmonize the stomach. Biăn dòu fortified the spleen, removed dampness, and arrested diarrhea. Bái zhú was replaced by cāng zhú to strengthen the effect of dispelling dampness and dissolving fluid retention. 2. Polysialia 1 Feng Shi-Lun. Hundreds of Famous TCM Clinical Practitioners of the Past Ten Decades·Hu Xi-shu中国百年百名中医临床家丛书·胡希恕. Beijing: China Press of Traditional Chinese Medicine; 2001. p. 147.

Chen, 26-year-old female, suffered from polysialia for over three months. This patient was hospitalized in a mental hospital for a mental disease relapse, which was treated with chlorpromazine, clozapine, etc. She had profuse discharging of saliva with occasional spitting. Moreover, she discharged saliva involuntarily during her sleep, wetting part of her pillow, causing her to be depressed. The Western medications she was taking included clozapine 500 mg/d, and anisodamine 15 mg/d. She was overweight, had a light red tongue with a wet, greasy coating in the middle of the tongue, and a slippery pulse. Her condition was differentiated as a failure of the spleen to transport and the stomach to descend, causing the fluid to accumulate into saliva. The proper treatment was to warm the center and dissipate cold, supplement qi, and fortify the spleen by using a modified Lĭ Zhōng Tāng. The prescription was composed of dăng shēn 15 g, bái zhú 10 g, gān jiāng 10 g, wú zhū yú 6 g, cāng zhú 10 g, and zhì gān căo 6 g.

After taking six doses, the amount of saliva decreased a lot, years of scanty sweating alleviated as well. After taking another 15 doses, most of her symptoms had cleared. Xiāng Shā Yăng Wèi Wán was thereafter prescribed for over one month, and all of her symptoms were eliminated with no reoccurrences.1 Comments: The chief complaint was polysialia. The Treatise on Cold Damage states that phlegm and retained fluids should be resolved with warm medicinals. It also states that when one is recovering from a serious illness, if a patient has suffered polysialia for a long time, it is due to cold in the chest that should be warmed by pills. Lĭ Zhōng Wán is suggested. Judging from her weight, pale tongue, wet greasy tongue coating, and slippery pulse, the syndrome was due to yang deficiency of the spleen-lung, and fluid retention. Thereby, a modified Lĭ Zhōng Wán was used to warm the center, dispel cold, supplement qi, and fortify the spleen. Wú zhū yú and cāng zhú are added to warm the center and dry dampness, direct counterflow downward, and dissolve fluid retention.

Xiăo Jiàn Zhōng Tāng ⼩建中汤Minor CenterFortifying Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Decoct all the six medicinals with 7 sheng of water until 3 sheng is left, remove the remainder and add the yí táng to melt over a mild flame. Take 1 sheng of the warm decoction each time, three times a day. (Modern use: add yí táng into the prepared decoction, melt it over mild heat, and take warm twice a day.)

Formula Indications 1 Yin Chen-fang. Modified Lĭ Zhōng Wán Treating Polysialia 理中丸加味治疗药物性多涎症1 例. Journal of Traditional Chinese Medicine. 1997; (11): 657.

Deficiency-cold of the middle jiao, disharmony of the liver and spleen, characterized by abdominal spasms and pain which can be lessened by

warmth and pressure, fatigue and lack of strength, shortness of breath, palpitations, dysphoria, pale complexion, or sore limbs, vexing heat in the palms, dry throat, a pale tongue with white coating, and a thready, wiry pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by deficiency-cold of the middle jiao, and disharmony of the liver and spleen due to insufficient source qi that cannot initiate transformation. Deficiency-cold of the middle jiao, as well as the liver, restrains the spleen and causes abdominal spasms and pain that can be lessened by warmth and pressure. The spleen and stomach are the source of qi and blood production. When there is deficiency-cold of the middle jiao, there is no source for transportation and transformation, which leads to deficiency of both qi and blood and causes symptoms such as palpitations, pale complexion, fever, and a dry throat. Although the symptoms vary, they all belong to deficiency-cold in the middle jiao. The treatment is to warm the center, supplement deficiency, nourish yin, harmonize the interior, and relax spasm to relieve pain.

Formula Actions Warms the center, supplements deficiency, harmonizes the interior, and relaxes spasms.

Formula Analysis

Unique Combination Features The main functions of this formula are to treat the liver and spleen simultaneously, harmonize yin and yang, warm the center, and dispel cold.

Further Clarification 1. About the indications The symptoms of this formula are very complicated. Based on the pathological features, these syndromes can be categorized into three types:

● deficiency-cold of the middle jiao fails to warm the middle and causes chronic abdominal pain.

● insufficient source qi due to the deficiency of the middle jiao, as well as, qi and blood deficiency that fails to nourish the body and causes palpitations, aching pains of the limbs, and a sallow complexion.

● qi and blood deficiency leads to yang impairment that affects yin and causes the disharmony of yin and yang, thereby yin deficiency causes vexing heat of the palms, dry throat, nosebleed, and spermatorrhea; yang deficiency produces cold, which is the cause of abdominal urgency and abdominal pain. All of the symptoms mentioned above are related to deficiency-cold of the middle jiao that leads to insufficient source qi or disharmony of yin and yang. It is important to stress that although the pattern is related to deficiency of both yin and yang, deficiency-cold of the middle jiao is of primary importance. 2. About sháo yào Within the prescription, sháo yào is usually referred to as bái sháo. It is stir-fried because of its cold property. There are three important aspects regarding the use of bái sháo in Xiăo Jiàn Zhōng Tāng:

● bái sháo can transform yin in order to harmonize yang. Bái sháo astringes yin and nourishes blood to replenish yin and blood. When used together with other sweet medicinals, bái sháo promotes the production of yin-fluids.

● bái sháo can relieve spasms and pain. Abdominal pain is the symptom that is mentioned the most often in the original formula discussion, as well as other related discussions, and bái sháo is effective at relieving pain; therefore, it is used at a heavy dose.

● bái sháo can soften the liver to reinforce the spleen. For cases of liver restraining the spleen, bái sháo can nourish the blood and soften the liver by

reducing the liver fire, which helps with the transportation of the spleen.

Formula Applications 1. Essential pattern differentiation This formula is used to warm the center, supplement deficiency, relax spasms, and relieve pain. It is also commonly used to soften the liver and rectify the spleen. This clinical pattern is marked by:

● spasms and pain in the abdomen, which can be reduced by warmth and pressure

● pale tongue body ● thready, wiry pulse 2. Modifications

3. Modern applications This formula is indicated for gastric and duodenal ulcers, chronic hepatitis, chronic gastritis, neurasthenia, aplastic anemia, fever due to deficiency-cold of the middle jiao, and disharmony of the liver and spleen. 4. Cautions and contraindications

This formula is not suitable for vomiting or abdominal fullness. It is prohibited for pain in the stomach cavity due to vigorous fire resulting from yin deficiency.

Associated Formulas Huáng Qí Jiàn Zhōng Tāng (Astragalus Center-Fortifying Decoction, 黄芪建中汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Decoct the six medicinals with 7 sheng of water until 3 sheng left, remove the remainder and add yí táng to melt over a mild flame. Take 1 sheng of warm decoction three times a day. [Actions] Warms the center and boosts qi. Harmonizes the interior and relaxes spasms. [Applicable Patterns] Deficiency of yin, yang, qi, and blood. Symptoms include: abdominal spasms and pain which can be lessened by warmth and pressure, emaciation, sallow complexion, palpitations, shortness of breath, spontaneous sweating and night sweat.

Dāng Guī Jiàn Zhōng Tāng (Chinese Angelica Center-Fortifying Decoction, 当归建中汤) [Source] Supplement to ‘Important Formulas Worth a Thousand Gold Pieces’ (Qiān Jīn Yì Fāng,千⾦翼⽅) [Ingredients]

[Preparation and Administration] Decoct the six medicinals with 1 dou of water until 3 sheng left, remove the remainder and add yí táng to melt over a mild flame. Take 1 sheng of warm decoction three times a day. For patient with severe deficiency, increase the dosage of yí táng to 6 liang (30 g). [Actions] Warms and supplements qi and blood, relaxes spasms and relieves pain. [Applicable Patterns] Postpartum weakness. Symptoms include: abdominal pain, weak breathing, spasms of lower the abdomen affecting the waist, back, and the appetite. Dà Jiàn Zhōng Tāng (Major Center-Fortifying Decoction, ⼤建中汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Decoct the three medicinals with 4 sheng of water until 2 sheng left, remove the remainder and add yí táng to melt over a mild flame and boil it until 1.5 sheng left. Take the warm decoction two times a day. [Actions] Warms the center and supplements deficiency, directs counterflow downward and relieves pain. [Applicable Patterns] Severe pain in the stomach and abdomen due to yang debility in the middle jiao and cold accumulation. Symptoms include: abdominal pain that involves the chest and stomach, which is severe and moves around or as if a lump is moving up and down causing harsh pain, serious vomiting, unable to eat, extremely cold extremities, a pale tongue, a white, watery tongue coating, and a deep, slow pulse. Xiăo Jiàn Zhōng Tāng, Huáng Qí Jiàn Zhōng Tāng, Dāng Guī Jiàn Zhōng Tāng, and Dà Jiàn Zhōng Tāng all warm the center and supplement deficiency. Among them, Xiăo Jiàn Zhōng Tāng is mainly composed of acrid and sweet medicinals, which are assisted by a large dose of sháo yào. It boosts yin due to the effect of sour and sweet medicinals used in combination, and is indicated for middle jiao yang deficiency and ying-yin insufficiency. Huáng Qí Jiàn Zhōng Tāng is created when huáng qí is added to Xiăo Jiàn Zhōng Tāng, which strengthens its effect to boost qi and fortify the center by raising yang and producing yin, so that all symptoms due to deficiency can be cured. Dāng Guī Jiàn Zhōng Tāng is indicated for

postpartum weakness. Considering that there is a general deficiency of the channels and blood vessels, dāng guī is used. It is bitter-acrid and sweetwarm, so it can effectively supplement and harmonize blood. Compared with the other two formulas, Xiăo Jiàn Zhōng Tāng is focused to warm the yang, Huáng Qí Jiàn Zhōng Tāng is more proficient to boost qi, and Dāng Guī Jiàn Zhōng Tāng is suitable to harmonize the blood and relieve pain. In addition, Dà Jiàn Zhōng Tāng consists only of acrid-sweet medicinals that warm the middle jiao. Its ability to supplement deficiency and dissipate cold is much stronger than Xiăo Jiàn Zhōng Tāng. Additionally, it can also direct counterflow downward and arrest vomiting; therefore, it is named Dà Jiàn Zhōng because it treats abdominal pain and vomiting due to yang deficiency in the middle jiao and cold excess.

Case Studies 1. Abdominal pain Wang, had abdominal pain, which was reduced with pressure, cold qi flowing downward when the pain occurred, slight aversion to cold, and a weak, wiry pulse. The pattern was diagnosed as liver restraining the spleen, and Xiăo Jiàn Zhōng Tāng was used. The prescription was composed of guì zhī 3 qian, bái sháo 6 qian, shēng gān căo 2 qian, shēng jiāng 5 pian, dà zăo 12 pieces, and yí táng 1 sheng.1 Comments: Cold qi flowing downward from the chest to the abdomen caused abdominal pain. Considering the other symptoms, the differentiation was deficiency-cold of the middle jiao and liver restricting the spleen. And the patient was therefore treated with Xiăo Jiàn Zhōng Tāng. 2. Palpitations and abdominal pain

1 Cao Ying-fu. Records of Experiments with Classical Formulas经⽅实验录. Shanghai: Shanghai Scientific and Technical Publishers; 1979. p. 154.

Qiu, a 13-year-old male, tested positive HbsAg (+) and HbeAg (+) indicators when he underwent a physical examination. The other liver indexes were normal, and he was without any symptoms or discomfort. Based on the results of the test, he then took Chinese medicine in the inpatient department. Initially he felt nothing unusual while receiving the Chinese medicine. However, two months later he developed a poor appetite, dizziness, occasional palpitations that became worse after activities such as running, abdominal pain, sallow complexion, and lassitude. A liver function test showed that his ALT had increased to 146U, so he turned to another doctor looking for better treatment. In over one month, his ALT decreased to approximately 100U. His previous formula was composed of chái hú, huáng qín, băn lán gēn, yīn chén, zhī zĭ, zé xiè, chì sháo, bái sháo, bái huā shé shé căo, tián jī huáng, zhĭ qiào, chuān liàn zĭ, etc. Generally speaking, although the formula went through a lot of changes, these formulas were primarily used to soothe the liver, promote gallbladder function, clear heat, drain dampness, and sometimes fortify the spleen. The treatment was mainly based on the methods of draining and attacking. He had a wiry, moderate pulse on the left and a thready, choppy pulse on the right, a pale tongue body, and a white, greasy coating. According to these manifestations the prescription was composed of guì zhī 10 g, bái sháo 15 g, yí táng 30 g, zhì gān căo 6 g, dà zăo 4 pieces, shēng jiāng 10 g, dăng shēn 15 g, bái zhú 10 g, fú líng 15 g, and shā rén 3 g (added later). Seven doses later, his ALT decreased to 72U, his appetite and spirit improved, his abdominal pain was almost gone, and he had occasional palpitations, but he had no more dizziness. His tongue coating turned normal, but his pulse was still the same. Since this formula was effective, it was continued with some modifications. The patient visited the doctor five times and took thirty-five doses in total

until all the symptoms cleared and his ALT returned to the level of a person in normal health. At that point he was told to stop taking the medicinals and continue to observe his condition.1 Comments: In this case, the patient had HBV but without checking the pulse and tongue, the previous doctor mistook a virus of Western medicine as a fire toxin. He then applied large doses of bitter-cold medicinals to drain fire. The doctor was not aware that bitter-cold medicinals tend to injure the spleen and stomach and consume qi and blood. The patient’s pulse was wiry, moderate on the left and thready, choppy on the right; combined with the other symptoms such as vertigo, paroxysmal palpitations, abdominal pain, withered-yellow complexion, a pale tongue body with a white and greasy coating, his condition corresponds with the pathogenesis of Xiăo Jiàn Zhōng Tāng and is due to yang deficiency of the middle jiao and ying-yin insufficiency. Therefore, Jiàn Zhōng Tāng was applied to warm the center, supplement deficiency, harmonize the interior, and relax spasms. The previous draining treatment had injured his spleen heavily, so dăng shēn, bái zhú, fú líng, and shā rén were used to fortify the spleen and harmonize the stomach. When a TCM doctor treats diseases, the results of a Western medical examination can be used as reference; however, not all viruses can be diagnosed as a fire toxin or heat toxin. This misunderstanding may delay a proper TCM diagnosis and treatment of the disease. This case provides powerful evidence of this issue.

Wú Zhū Yú Tāng 吴茱萸汤Evodia Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Decoct these four medicinals with 7 sheng of water, boil the decoction until 2 sheng of water remain, and remove the dregs. Take the warm decoction three times a day. (Modern use: prepare as a decoction.) 1 Ou-yang Huang-ping. Case Analysis of Xiăo Jiàn Zhōng Tāng⼩建中汤救误1例分析. Jiangxi Journal of Traditional Chinese Medicine. 2000; (6): 28.

Formula Indications Wú Zhū Yú Tāng is indicated for patterns of liver and stomach deficiency-cold with the upward reversal of turbid yin. The pattern is characterized by nausea after meals, acid regurgitation, belching, drooling of cold frothy saliva, fullness in the chest, stomach pain, vertex headache, aversion to cold, cold limbs with reversal counterflow cold of the four limbs, diarrhea, vexation and agitation, restlessness, a pale white tongue body and a white, slippery tongue coating, and a deep, wiry or slow pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by deficiency-cold of the liver and stomach and the upward reversal of turbid yin. Due to the deficiency-cold of the liver and stomach, the stomach fails to descend and causes an upward reversal of turbid yin, which causes nausea after meals, acid regurgitation, belching, and drooling of cold frothy saliva. The jueyin channel passes through the stomach, belongs to the liver, and connects upward with the associated du mai at the vertex. The turbid yin of the stomach travels upward along the liver channel to disturb the head, which causes a vertex headache. Fullness of the chest and stomachache are caused by turbid yin obstruction and the disturbance of qi circulation. The body is unable to get warm because of the deficiency-cold of the liver and stomach and yang deficiency, which leads to an aversion to cold and cold limbs. The spleen and stomach are located in the middle jiao. Stomach illness affects the spleen causing the spleen’s failure to ascend the clear, and thus there is diarrhea. The pale tongue body with white tongue coating and the deep, wiry, and slow pulse are due to the deficiency-cold. The proper therapeutic method is to warm the center, supplement deficiency, direct counterflow downward, and arrest vomiting.

Formula Actions Warms the center and supplements deficiency, directs counterflow downward and arrests vomiting.

Formula Analysis

Unique Combination Features This formula warms the center and directs counterflow downward. The method of supplementing and boosting is used with warming and descending.

Further Clarification The meaning of shēng jiāng used at a heavy dosage The dosage of shēng jiāng in this formula is 6 liang. Although this formula addresses multiple channels—yangming, shaoyin, and jueyin, they share the same pathogenesis of middle jiao deficiency-cold and upward reversal of turbid yin. For this reason a heavy dosage of shēng jiāng can warm the stomach, dissipate cold, direct counterflow downward, and arrest vomiting. It also helps the chief medicinal, wú zhū yú warm the center and direct counterflow downward, which descends the overflowed qi and circulates the qi movement.

Formula Applications

1. Essential pattern differentiation Wú Zhū Yú Tāng is a common formula used to treat deficiency-cold of the liver and stomach and the counterflow of turbid yin. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency-cold of the liver and stomach: chronic gastritis, vomiting of pregnancy, nervous vomiting, nervous headache, and aural vertigo. 4. Cautions and contraindications This formula is prohibited for vomiting due to stomach heat or yin deficiency and for headaches due to the hyperactivity of liver yang.

Case Studies 1. Headache

Chen, a 49-year-old male suffered with headaches, especially at the vertex of his head. His headaches were accompanied with vertigo and dizziness, profuse saliva, poor sleep, dark complexion, a slippery tongue coating, and a wiry, slow pulse. All of the symptoms above resulted from cold traveling along the jueyin channels, disturbing the clear yang. He was prescribed: wú zhū yú 15 g, shēng jiāng 15 g, dăng shēn 9 g, and dà zăo 12 pieces. After taking two doses his headache was gone, but his poor sleep remained. He was prescribed three doses of Guī Pí Tāng, which resolved his poor sleep.1 1 Liu Du-zhou. Clinical Guidance of Classics经⽅临证指南. Tianjin: Tianjin Science and Technology Press; 1993. p. 126.

Comments: The liver channel reaches the vertex of the head. When pathogenic yin-cold travels along the channel, headache, vertigo, and dizziness may occur. When there is deficiency-cold of the spleen and stomach, cold fluid retention, dysfunction of the liver qi, stomach qi ascending counterflow, symptoms of drooling of frothy saliva, a watery tongue coating, and a deep, slow, and weak pulse may occur. Since the pathogenesis was spleen-stomach weakness with cold accumulation in the middle jiao and stomach qi ascending counterflow, Wú Zhū Yú Tāng was applied to warm the center, supplement deficiency, direct counterflow downward, and arrest vomiting. 2. Vomiting due to cold in stomach Yang, a 42-year-old male had occasional vomiting caused by discomfort after eating for nearly ten years. He would vomit a small amount, of which the contents were undigested food and frothy saliva. Over the past year, his situation worsened. The continuous vomiting occurred one or two hours after each meal and got worse in cold weather. He took formulas to harmonize his stomach and direct counterflow downward in order to arrest

vomiting and fortify the stomach, which did not work. At the time of his visit, the symptoms were counterflow cold of the limbs, poor digestion, and a deep and slow pulse. Wú Zhū Yú Tāng was prescribed composed of wú zhū yú 12 g, rén shēn 6 g, shēng jiāng 30 g, and dà zăo 5 pieces. After taking three doses, the vomiting improved fifty to sixty percent. However, after taking another seven doses, his vomiting returned to the original condition. The reason was because he replaced shēng jiāng with salty ginger, which worsened the situation rather than improving it. Later, shēng jiāng was used again and the vomiting improved seventy to eighty percent after four doses and his appetite and the reversal counterflow cold of the limbs improved. After taking twenty doses of modified Wú Zhū Yú Tāng, his vomiting ceased. There was no reoccurrences following one year of observation.1 Comments: This chronic disease had a history of ten years, and gradually worsened. Continuous vomiting would occur one or two hours after each meal and it was especially worse in cold weather. The counterflow cold of the limbs, poor digestion, deep, slow pulse belong to yang weakness and yin-cold accumulation of the middle jiao. Wú Zhū Yú Tāng was applied to warm the center, supplement deficiency, direct counterflow downward, and arrest vomiting. Moreover, a large dose of shēng jiāng was used to dissipate cold and arrest vomiting. Since Wú Zhū Yú Tāng matches the pathogenesis exactly, the ten-year-old disease was cured.

Section 2 Formulas that Restore Yang and Rescue Counterflow Formulas that restore yang and rescue counterflow are used to treat critical disease patterns such as debilitated yang qi, yin-cold excess, exuberant yin repelling yang, and floating yang. These patterns are marked by reversal counterflow cold of the four limbs, debilitated spirit, aversion to cold, lying in bed curled up, cold sweating, and a feeble, impalpable pulse. These formulas mainly combine warm or hot medicinals such as fù zĭ and gān jiāng with qi-boosting medicinals such as rén shēn in order to rescue yang from desertion. Common formulas in this category are Sì Nì Tāng and Huí Yáng Jiù Jí Tāng. 1 Zhao Ming-rui. Development of Classics 经⽅发挥. Shanxi: Shanxi People’s Publishing House; 1982. p. 144.

Sì Nì Tāng 四逆汤Frigid Extremities Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Decoct these three medicinals with 3 sheng of water, boil them until 1 sheng and 2 ge of water is left, remove the dregs, and take the warm decoction two times a day. Patients with a strong constitution can take a larger piece of fù zĭ and double the amount of gān jiāng (3 liang). (Modern use: prepare as a decoction.)

Formula Indications Reversal counterflow cold of the four limbs is due to heart and kidney yang deficiency. This pattern is marked by reversal counterflow cold of the four limbs, aversion to cold, lying in bed curled up, debilitated spirit, desire to sleep, pale complexion, stomach pain, diarrhea, vomiting, no thirst, a white, slippery tongue coating, and a feeble, thin pulse.

Analysis of Fundamental Pattern Pathogenesis This formula is indicated for heart and kidney yang deficiency and yincold excess. Yang and qi deficiency fails to warm the body and extremities, so there is reversal counterflow cold of the four limbs, lying in bed curled up, and averse to cold. Yang and qi deficiency fails to activate the blood circulation, so there is a feeble, thin pulse. It is said in Basic Questions, “Yang and qi in hardness can activate the spirit, and in softness can nourish the tendons.” [1] In the current situation, the heart yang is weak and it cannot nourish the spirit, so there is a desire to sleep. Moreover, the kidney yang is also weak and fails to warm the spleen causing disharmony of its ascending and descending function, marked by stomach pain, diarrhea, and vomiting. This is considered to be a pattern of deficient yang and excessive yin, which can only be treated with strong pungent, hot medicinals of a pure yang

nature to break yin-cold and rescue yang from desertion marked by reversal counterflow cold of the four limbs, severe thoracic and abdominal pain, and chronic headache.

Formula Actions Restores yang to rescue from counterflow.

Formula Analysis

Further Clarification Debate about the usage of crude fù zĭ In the original Sì Nì Tāng prescription, crude fù zĭ is used, however some people later in history doubt that it is crude since fù zĭ is toxic. From the perspective of safety, they consider that fù zĭ should not be used crude in formulas. However, most Chinese medicine practitioners fully support

Zhang Zhong-jing’s instructions. They base their opinion upon two aspects. First, crude fù zĭ is stronger to rescue the yang. Second, its toxicity can be reduced when it is decocted for a long time, which achieves an effect that is similar to when it is combined with gān jiāng and gān căo.

Formula Applications 1. Essential pattern differentiation Sì Nì Tāng is a fundamental formula to restore yang to rescue from counterflow. This clinical pattern is marked by:

2. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of debilitated yang and yin exuberance: myocardial infarction, cardiac failure, severe vomiting or diarrhea due to acute gastroenteritis, and profuse sweating due to acute disease resulting shock. 3. Cautions and contraindications Take the decoction cold if vomiting appears. Since there is all acrid and hot medicinals in this formula, it is not suitable for long-term usage. Once the limbs become warm, this formula should not be taken anymore. It is prohibited for the pattern of true heat with false cold.

Associated Formulas Tōng Mài Sì Nì Tāng (Channel-Unblocking for Frigid Extremities Decoction, 通脉四逆汤)

[Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct the three medicinals with 3 sheng of water until 1.2 sheng left, remove the remainder and take the warm decoction two times a day. [Actions] Breaks yin and restores yang to connect the interior and exterior. [Applicable Patterns] Shaoyin pattern, exuberant yin repelling yang. Symptoms include: diarrhea with undigested food, internal cold and external heat, reversal counterflow cold of limbs, feeble, impalpable pulse, aversion to cold, red complexion, bellyache, nausea or vomiting, sore throat, diarrhea stops but the pulse is still impalpable. Sì Nì Jiā Rén Shēn Tāng (Frigid Extremities Decoction Plus Ginseng, 四逆加⼈参汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct the four medicinals with 3 sheng of water until 1.2 sheng left, remove the remainder and take the warm decoction two times a day. [Actions] Restores yang to rescue from counterflow, boosts qi, and rescues from desertion. [Applicable Patterns] Shaoyin pattern. Symptoms include: aversion to cold, fever, reversal counterflow cold of the four limbs, lying in bed curled up, a feeble pulse and diarrhea, diarrhea stops while other symptoms remains. Bái Tōng Tāng (Scallion Yang-Freeing Decoction, ⽩通汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct the four medicinals with 3 sheng of water until 1 sheng left, remove the remainder and take the warm decoction two times a day. [Actions] Breaks yin and restores yang to connect the upper and lower. [Applicable Patterns]

Shaoyin pattern, exuberant yin repelling yang. Symptoms include: reversal counterflow cold of the hands and feet, diarrhea, a feeble pulse, and a red complexion. Treatise on Cold Damage says: For continuous diarrhea, reversal counterflow cold of the limbs, severe thoracic and abdominal pain, chronic headache, impalpable pulse, nausea, and vexation, add 1 ge (5 ml) of pig bile and 5 ge (25 ml) of human urine, called Bái Tōng Tāng with pig bile. Shēn Fù Tāng (Ginseng and Aconite Decoction, 参附汤) [Source] Categorized Synopsis of the Whole (Zhèng Tĭ Lèi Yào, 正体类要) [Ingredients]

[Preparation and Administration] Decoct the four medicinals with 2 zhan of water and 10 pieces of shēng jiāng until 8 fen left, remove the remainder and take the warm decoction three times a day. [Actions] Boosts qi to consolidate and restores yang. [Applicable Patterns] Yang and qi collapse. Symptoms include: reversal counterflow cold of the four limbs, continuous cold sweating, shallow breathing, and a feeble, impalpable pulse.

Recorded in Treatise on Cold Damage, Tōng Mài Sì Nì Tāng, Sì Nì Jiā Rén Shēn Tāng, and Bái Tōng Tāng are all indicated for the pattern of shaoyin yang deficiency. They share the same basic formula composition of Sì Nì Tāng, but they are different in their applications. Aside from counterflow cold of the four limbs, which is the common symptom of the shaoyin pattern, Tōng Mài Sì Nì Tāng is indicated for aversion to cold, red complexion, stomach pain, nausea or vomiting of frothy saliva, sore throat, and diarrhea that stops but the pulse is still impalpable. These are signs of exuberant yin repelling yang and yang collapse. The dosages of shēng jiāng and fù zĭ have been increased based on Sì Nì Tāng’s ability restore the yang and pulse. This is the reason why the notes said, “take the warm decoction and the pattern will be resolved when the pulse is palpable.” [2] When vomiting and diarrhea have resolved, but symptoms of severe cold after sweating, spasms of the limbs, and a feeble, impalpable pulse remain, it indicates that both yin and yang have collapsed. Bitter cold bile must be used to prevent cold from counter-restricting the decoction, and to conduct deficient yang back into yin. This works fantastically as a paradoxical assistant. Because of these reasons the notes say, “replace with sheep bile if pig bile is unavailable.” Diarrhea is one of the primary symptoms of the Sì Nì Tāng; however, when the diarrhea stops and counterflow cold of the four limbs remains it reflects severe damage of qi and blood. Therefore, rén shēn is added to Sì Nì Tāng to strongly reinforce the essential qi, boost qi, and rescue from desertion in order to restore yang and generate yin. In clinical practice, Sì Nì Jiā Rén Shēn Tāng can be used to urgently treat shortness of breath in a Sì Nì Tāng pattern. To make Bái Tōng Tāng, remove gān căo, decrease the dosage of gān jiāng, and add cōng bái to Sì Nì Tāng. Bái Tōng Tāng is indicated for yin-

cold exuberance in the lower jiao. The emergency treatment is to unblock yang in order to break yin and prevent exuberant yin from expelling yang. The combination of acrid, warm cōng bái assisted by gān jiāng and fù zĭ unblocks the yang and restores the pulse. In the case of severe diarrhea, yinfluids must be heavily consumed; hence the dosage of gān jiāng is lowered in order to decrease its dry, hot effect. This is what is means “protecting yinfluids”. Continuous diarrhea, reversal counterflow cold of the limbs, severe thoracic and abdominal pain, chronic headaches, impalpable pulse, nausea, and vexation are caused by the crisis of yin exuberance internally that causes yang to collapse upward and yin to collapse downward. Urgent treatment requires the use of acrid and hot medicinals to unblock yang and restore the pulse. Bile and urine are used to enrich yin and harmonize yang, which is an application of paradoxical assistant method. It is said in Treatise on Cold Damage, “after taking the decoction, an abnormal forceful pulse is dangerous and a tender and continuous pulse is expected.” [3] Furthermore, the notes mentioned that, “if bile is unavailable it does not matter too much,” which indicates that it is human urine that is most important. All these above are the details of Bái Tōng Tāng. Readers need to grasp the true meaning of the paradoxical assistant method found in Tōng Mài Sì Nì Tāng through the application of bile. Shēn Fù Tāng is a formula that drastically rescues yang from collapse. Besides the indications mentioned above, this formula is also indicated for collapse due to severe weakness after an illness, postpartum diseases, menstrual metrorrhagia, chronic abscesses and ulcers, blood desertion, and yang collapse, etc. As soon as the yang is recovered and the disease is stable, the treatment should be adjusted according to pattern identification. The medicinals used to urgently rescue yang are not intended for long-term

consumption. Their use should be stopped once they have achieved their purpose in order to prevent damage to yin and the consumption of blood.

Case Studies 1. Yin exuberance and yang collapse Mr. Su’s wife, who is over 30 years old, was exposed to cold water during her menstrual period, and suddenly began to shiver that night. She went into a heavy sleep and fell unconsciousness, her pulse was feeble, thin, and thready and she had reversal counterflow cold of the limbs. She was treated right then by bleeding shuǐ gōu (DU 26) and shí xuān (EX-UE11). The blood was dark purple and hard to squeeze out. She could feel the pain of the needle prick and even woke when she was needled. But, she would just fall back asleep again. Her condition was differentiated as yin exuberance, yang weakness, and qi and blood stagnation. The emergency treatment needed was to warm the channels and dissipate cold to rescue yang from collapse. Sì Nì Tāng was prescribed, composed of fù zĭ (processed) 8 qian, gān jiāng 4 qian, and zhì gān căo 4 qian. The formula was decocted with water; the decoction was separated into four parts and one part was taken every thirty minutes. A member of the patient’s family asked, “Since the situation was so serious, why not feed her the whole decoction at one time so she could get well sooner?” The doctor answered, “That is exactly why I ask you to feed her slowly. The formula is dosed heavily, but she needs to take it gradually instead of all of it at once. This way the medicinals can work continuously and vitalize yang step by step in order to dissipate yin-cold. It’s like when the ice and snow melt away day by day when spring is coming. If she takes the entire decoction at once, her pulse may suddenly emerge. This would be like if the fierce sun hangs in the sky and all the ice and snow suddenly melts and ends in a disaster.” His explanation finally

convinced her family member. The patient’s four limbs turned warm once she took part of the decoction, her pulse became fine, and she regained consciousness.1 Comments: The patient used cold water during her menstrual period, which caused cold damage to the shaoyin channel and excessive internal yin-cold. Due to its warm nature, only Sì Nì Tāng could treat it. What is more, is that the administration method is very important. In this case, the patient was fed the decoction in four quarter sized servings, one serving each half-hour, so that the medicinals would work continuously to vitalize yang step by step. 2. Shaoyin yang desertion and yin-fluid exhaustion pattern Zhang, male, aged 14, contracted malaria during the summer. However, once the malaria was cured, he kept an improper diet that caused vomiting and diarrhea. At his initial visit the patient was in a heavy sleep, unconscious even when his name was called out for a long time. His symptoms and signs included counterflow cold of his limbs, oily sweating (particularly from the four limbs), a light red tongue, and a sunken, thready, weak pulse. His diarrhea and vomiting had already stopped. His body temperature was 35°C, and his blood pressure was 60/40 mmHg. His pattern was differentiated as yang desertion and yin-fluid exhaustion. He was prescribed shú fù zĭ 9 g, gān jiāng 6 g, zhì gān căo 6 g, and dăng shēn 12 g. He took two doses of the decoction and his limbs turned warm, mind cleared, abnormal sweating stopped, pulse recovered, and yang recovered. His blood pressure increased to 100/70 mmHg. He was then given one dose of Shēng Mài Săn because he was short of breath and a little thirsty; after which, he was cured. 2 1 Yu Chang Rong. Analysis to the Collection of Treatise on Cold Damage (revised edition) 伤寒 论汇要分析 (修订本). Fuzhou: Fuzhou Science and Technology Press; 1985. p. 144.

2 Xu Hong Cheng. Three Experiential Practice of Sì Nì Tāng 四逆汤治验三则. Guangxi Journal of Traditional Chinese Medicine. 1980; (1): 30.

Comments: The patient was a youngster; therefore, his yang qi was physiologically insufficient. In addition, he had just recovered from a serious disease that was followed by vomiting and diarrhea due to an improper diet, which worsened the situation. Finally, his zheng qi was severely damaged, which led to yin exhaustion and yang desertion. The treatment was to restore yang to rescue from counterflow. Sì Nì Tāng was applied to rescue yang from collapse, and dăng shēn was used to help boost qi. Since yang alone could not grow and yin alone could not increase, and the vomiting and diarrhea he had consumed fluids and yin, one dose of Shēng Mài Săn was prescribed. The patient was then finally cured.

Huí Yáng Jiù Jí Tāng 回阳救急汤Yang-Returning Emergency Decoction Source Text Six Texts on Cold Damage (Shāng Hán Liù Shū, 伤寒六书)

Formula Ingredients

Preparation and Administration Decoct the medicinals with 2 cups of water and 3 pieces of shēng jiāng. Before it is taken, mix shè xiāng 3 li (0.1 g) into the warm decoction. Stop taking the decoction once the hands and feet get warm. (Modern use: prepare as decoction, infuse shè xiāng.)

Formula Indications

This formula treats pathogenic cold directly attacking the three yin channels, causing yang weakness. This pattern is characterized by reversal cold of the limbs, debilitated spirit, desire to sleep, aversion to cold, lying curled up, vomiting and diarrhea, stomach pain, no thirst, shivering, greenish-purple nails and lips, frothy saliva, a pale white tongue body with a white tongue coating, and a deep, feeble or barely perceivable pulse.

Analysis of Fundamental Pattern Pathogenesis Huí Yáng Jiù Jí Tāng is indicated for a pattern of pathogenic cold that directly attacks the three yin, and exuberant cold that causes desertion of the weakened yang. The patient’s yang is chronically deficient, so the pathogenic cold can directly attack the three yin channels. This causes stomach pain, vomiting and diarrhea, reversal counterflow cold of the four limbs, debilitated spirit, desire to sleep, shivering, greenish-purple nails and lips, and a deep, feeble pulse or barely perceivable pulse. All these are the signs of internal yin excess and yang weakness, and possibly yang collapse. The treatment is to restore yang in order to rescue from desertion, and boost qi to generate the pulse.

Formula Actions Restores yang to rescue from desertion, boosts qi and engenders the pulse.

Formula Analysis

Further Clarification About the name of this formula Looking at the indications, counterflow cold of the four limbs, fear of cold, and the other symptoms are due to yang deficiency. Vomiting and diarrhea, and mental fatigue are due to original qi weakness, nearing collapse. These are all symptoms of a Sì Nì Tāng pattern. Rén shēn, ròu guì, and wŭ wèi zĭ are used in the formula to warm, supplement, and astringe in order to restore yang and generate the pulse. This is why it is named Huí Yáng Jiù Jí (restore yang and rescue urgency); it indicates that the formula uses a large amount of warm medicinals to rescue yang from collapse.

Formula Applications 1. Essential pattern differentiation Huí Yáng Jiù Jí Tāng is the basic formula used to treat pathogenic cold directly attacking the three yin, causing yang weakness.This clinical pattern is marked by:

2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of yang collapse and desertion: severe vomiting and diarrhea due to acute gastroenteritis, shock, and cardiac failure. 4. Cautions and contraindications A small amount of shè xiāng is used in this formula. Stop taking the decoction once the hands and feet get warm.

Case Studies 1. Coma due to vomit and diarrhea Mrs. Zhao, a 50-year-old female, was in good health. In the summer of 1978, she suffered vomiting and diarrhea due to an excessively cold diet. One night, she had severe frequent diarrhea and vomiting of thin saliva. By early morning the next day, she was in coma, vomiting, with fecal

incontinence. She was diagnosed with acute gastroenteritis, dehydration, and shock. In the hospital, she was given sodium lactate, glucose, and saline by intravenous drip. She was treated for twentyfour hours, and the vomiting and diarrhea came under control, but she was still in coma. Her family member then asked for her to be treated with Chinese medicine. The blood pressure was 40/20mmHg, she had counterflow cold of four limbs, pale complexion, hollow eyes, borborygmus, tender belly, and she could respond when called loudly, but then she fell in coma again. She had a weak, thready, and rapid pulse, a white and greasy tongue coating, and profuse sweating on the forehead. Her condition was differentiated as pathogenic cold attacking the middle jiao, affecting the normal function of the spleen and stomach and the turbid and clear to interfere with each other causing vomiting and diarrhea. This caused yin and yang to suddenly collapse and the patient to fall into coma. In such an urgent situation, the treatment was to rescue yang from weakness and solidify yin from collapse, and a modification of Huí Yáng Jiù Jí Tāng was prescribed composed of zhì fù zĭ 12 g, gān jiāng 10 g, ròu guì 6 g, rén shēn 15 g, bái zhú 12 g, fú líng 15 g, chén pí 10 g, gān căo 6 g, bàn xià 12 g, huò xiāng 10 g, sū yè 10 g, and pèi lán 10 g. It was prepared as a decoction and the formula was taken during the day and at night. The second visit was on the next day. Her limbs were getting warm, spontaneous sweating was gone, vomiting and diarrhea ceased, the consciousness recovered, and the blood pressure increased to 70/40 mmHg. She urinated twice, about 400 ml each time. After taking another three doses of the same formula, she could sit with help, began a liquid diet, and after ten days of medical care, she was totally recovered.1 1 Ren Shou-shan. Three Emergency Cases Treated by Huí Yáng Jiù Jí Tāng 回阳救急汤治验急 症三则. Journal of Traditional Chinese Medicine.1984; (2): 25-26.

Comments: The internal yang is weak during the summer; moreover, excessive cold food causes yin-cold to directly attack the middle jiao. This

causes the spleen and stomach to fail to transport and transform. The turbid and clear materials are both disturbed, which leads to the dysfunction of descending and ascending. Thus there is sudden and severe vomiting and diarrhea, which heavily damages yin-fluids and accelerates the collapse of yang. This is marked by unconsciousness, counterflow cold of four limbs, oily sweating on the forehead, and a weak, thin pulse. The collapse of both yin and yang is an emergency situation, and the treatment method that needs to be executed urgently is to rescue yang. If yang recovers, it can then help with the circulation of qi and blood, and to rectify yin, otherwise it could turn into a worse situation that may lead to death. As a result, Huí Yáng Jiù Jí Tāng was prescribed in order to boost qi and consolidate the yang to rescue the counterflow cold. Aromatic huò xiāng, pèi lán, and sū yè were added to disperse turbidity and treat vomiting, and diarrhea, which is the reflection of treating both the root and the branch. By the next day, sweating, counterflow cold, vomiting, thirst were gone, and consciousness recovered. 2. Asthma Li, male, a 30-year-old male, had his initial visit on June 9th, 1975. The patient's constitution was chronically weak. He had phlegm and asthma for five years, which would occur in the spring and fall. Ten days ago, he walked in the rain which triggered chills and fever. The next day, he had a heavy cough and asthma, shortness of breath, sweating, breathing where he needed to raise his shoulders in order to get more air, and he could not lie on his back. He was diagnosed with asthmatic bronchitis and prescribed erythrocin and cortisol (hydrocortisone) for intravenous infusion, which did not work. However, subcutaneous injections of epinephrine could bring about a few hours of relief, so it was used several times a day to control the asthma. But the asthma would recur as soon as the cortisol was withdrawn, and the situation had not improved. I noticed that the patient had a pale

complexion, mental fatigue, breathless, profuse sputum, continuous gurgling due to retention of phlegm in throat, and profuse sweating on the forehead. Lately, he only ate a little because of his poor appetite, fatigue, frequent and clear urine, loose stool, and general sweating when the asthma occurs that would soak his shirt all the way through, tidal cold palms, and an aversion to cold and wind. His pulse was soft and rapid and his tongue was puffy with teeth marks and a thin, white coating. His pattern was differentiated as congenital insufficiency failing to nourish the lung causing phlegm retention, thus the lung could hardly purify and descend qi. Therefore, in the spring and fall, the changing climate would stir the hidden phlegm and induce asthma. In this case, he was attacked by cold wind, which invaded his weakest part where there was hidden phlegm. So the chest yang was not able to help descend, and that was why asthma lasted long without any improvement. The yang deficiency failed to defend the exterior, so there was profuse and continuous sweating. The yang was extremely weak, so it was deteriorating towards collapse. The treatment was to urgently apply Huí Yáng Jiù Jí Tāng to restore yang and rescue from counterflow. The formula was composed of shú fù zĭ 10 g, gān jiāng 8 g, ròu guì 5 g, rén shēn 10 g, bái zhú 10 g, fú líng 15 g, chén pí 10 g, gān căo 6 g, bàn xià 10 g, wŭ wèi zĭ 10 g, and zhì má huáng 8 g. He was prescribed two doses; one dose was used each day prepared as a decoction. His second visit was on June 15th. The profuse sweating had stopped, his hands and feet got warm, his asthma was relieved, and he was able to lie on his back. His pulse was a little slippery but not rapid. The yang was gradually recovering and able to disperse yin-cold. Tíng lì zĭ 10 g and xìng rén 10 g were added to the formula. He was prescribed four doses to use in four days; one dose each day prepared as a decoction.

His third visit was on June 20th. The cough and asthma were under control, it was easy for him to expectorate, he was able to do some activities outside, his appetite increased, his pulse was thin, slippery, and strong, the teeth marks were gone, and the tongue coating was thin and white. The decoction was changed to pills in order to slowly regulate the spleen and stomach, and thus consolidate the root. After taking the medicinals for three months, all the symptoms were relieved and the asthma has not recurred to date.1 Comments: Insufficient yang of the shaoyin channel lead to phlegm and fluid retention. In addition, the taiyang channel was attacked by wind cold, which worsened the yang injury and invaded the weakness at its weakest part, where the phlegm was hiddened inside. The chest yang was not able to help descend, that is why there is breathless, sweating, coughing, and wheezing. Yang deficiency failed to defend the exterior, so there was profuse and continuous sweating, which further damaged yang. The extremely weak yang could deteriorate and collapse, so the urgent treatment was to use Huí Yáng Jiù Jí Tāng in order to restore yang and rescue from counterflow. Shè xiāng was replaced by má huáng to protect the lung qi from being overdispersing. Wŭ wèi zĭ was used to help diffuse the lung and relieve panting, and the formula had the ability to both scatter and astringe. Once the severe sweating was gone, the hands and feet were getting warm, and the asthma was also relieved, tíng lì zĭ and xìng rén were added to reduce phlegm and relieve coughing and panting. Then finally, the method of rectifying and reinforcing the spleen and stomach was used to treat the root in order to achieve an overall recovery.

Section 3 Formulas that Warm the Channels and Expel Cold Formulas that warm the channels and expel cold are indicated for diseases caused by the pattern of cold accumulation in the channels. The main cause of this pattern is yang weakness, ying-blood insufficiency, and cold invading the channels, which results in poor blood circulation. The signs and symptoms include counterflow cold of the hands and feet, limb pain, and yin carbuncles. The formulas that warm the channels and expel cold are often composed of channel-warming and coldexpelling medicinals such as guì zhī, and xì xīn, as well as, blood-nourishing medicinals such as dāng guī, bái sháo, and shú dì huáng to fortify the blood. Common formulas in this category are Dāng Guī Sì Nì Tāng and Yáng Hé Tāng.

Dāng Guī Sì Nì Tāng 当归四逆汤Chinese Angelica Frigid Extremities Decoction Source Text reatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

1 Ren Shou-shan. Three Emergency Cases Treated by Huí Yáng Jiù Jí Tāng 回阳救急汤治验急 症三则. Journal of Traditional Chinese Medicine. 1984; (2): 25-26.

Preparation and Administration Decoct all seven medicinals with 8 sheng of water, boil them until 3 sheng of water is left, and remove the dregs. Take the decoction warm three times a day. (Modern use: prepare as a decoction.)

Formula Indications Counterflow cold of the limbs due to blood deficiency is characterized by counterflow cold of hands and feet, pain in the waist, thighs, lower legs, feet, shoulders, and back, no thirst, a pale tongue body with a white coating, and a deep, thin pulse or thin, impalpable pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by the combination of blood deficiency and cold accumulation in the channels, which result in poor blood circulation. The blood is chronically deficient and the channels have been invaded by pathogenic cold; therefore, there is poor blood circulation due to deficient blood obstructed by the pathogenic cold accumulated within the vessels. In this event, the hands and feet become very cold and the pulse is thin and impalpable because blood fails to supply the vessels and yang fails to reach the four extremities. Dāng Guī Sì Nì Tāng treats counterflow cold of the hands and feet. Specifically, it treats cold below the wrist and ankle, which

differs from counterflow cold of the four limbs. The proper treatment is to warm the channels, expel cold, nourish the blood, and unblock the channels.

Formula Actions Warms the channels to expel cold, nourishes the blood and unblocks the channels.

Formula Analysis

Unique Combination Features This formula combines treatment methods. The yang-warming and cold-expelling methods are combined, and the blood-nourishing and unblocking blood vessels methods are combined. Together they yield an ability to warm without drying and fortify without blocking.

Formula Applications 1. Essential pattern differentiation Dāng Guī Sì Nì Tāng is commonly used to nourish blood and warm the channels in order to expel cold. This clinical pattern is marked by:

● counterflow cold of the four limbs ● pale tongue body with a white coating ● thin, impalpable pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of blood deficiency and cold accumulation: thromboangitis obliterans, Takayasu's arteritis (pulseless disease), Raynaud’s phenomenon, polio, chilblain, dysmenorrhea, periarthritis of shoulder, and rheumatoid arthritis.

Associated Formulas

Dāng Guī Sì Nì Jiā Wú Zhū Yú Shēng Jiāng Tāng (Chinese Angelica Frigid Extremities Decoction Plus Evodia and Fresh Ginger, 当归四逆加 吴茱萸⽣姜汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Decoct the nine medicinals with 6 sheng of water and 6 sheng of wine until 5 sheng left, remove the remainder and take the warm decoction five times a day. [Actions] Warms yang and dispels cold, nourishes blood and unblocks blood vessels, harmonizes the center and arrests vomiting. [Applicable Patterns] Blood deficiency and cold accumulation, counterflow cold of hands and feet, accompanied with vomiting and painful abdomen due to stomach cold. Huáng Qí Guì Zhī Wŭ Wù Tāng (Astragalus and Cinnamon Twig Five Substances Decoction, 黄芪桂枝五物汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

[Ingredients]

[Preparation and Administration] Decoct the five medicinals with 6 sheng of water until 2 sheng left, remove the remainder and take the warm decoction three times a day. [Actions] Boosts qi and warms the channels, harmonizes the blood, and relieves bì. [Applicable Patterns] Blood bì. Symptoms include: numbness of the skin, and a choppy, tight, and unsmooth pulse. Dāng Guī Sì Nì Tāng, Dāng Guī Sì Nì Jiā Wú Zhū Yú Shēng Jiāng Tāng, and Huáng Qí Guì Zhī Wŭ Wù Tāng are all modifications of Guì Zhī Tāng. Dāng Guī Sì Nì Tāng is indicated for blood deficiency with pathogenic cold that has invaded and accumulated within the channels causing counterflow cold of hands and feet and pain. When there is vomiting and stomachache in addition to the symptoms indicated for Dāng Guī Sì Nì Tāng, Dāng Guī Sì Nì Jiā Wú Zhū Yú Shēng Jiāng Tāng should be used to treat stomach cold. Huáng Qí Guì Zhī Wŭ Wù Tāng is indicated for blood bì, which is characterized by numbness of the skin. Blood bì is caused by pathogenic wind that invades the surface of a person who has a weak constitution, blocking the blood vessels.

Comparison & Contrast Sì Nì Tāng vs. Dāng Guī Sì Nì Tāng vs. Sì Nì Săn

Continued

Recorded in the Treatise on Cold Damage, there are three formulas that have Sì Nì in their name: Sì Nì Săn, Sì Nì Tāng, and Dāng Guī Sì Nì Tāng. Although they all share the same indication of Sì Nì (counterflow cold of the four limbs), the pathogenesis and medicinals composition differ from each other. Patterns indicated by Sì Nì Săn are caused by external pathogens that travel along the channels and penetrate into the body. This causes yang to constrain inside the body, which then fails to spread to the extremities.

Therefore, the counterflow cold is limited to below the wrists and ankles and there are additional symptoms such as a fever and a wiry pulse. The type of counterflow cold that is indicated by Sì Nì Tāng is caused by internal yincold excess that yields yang too weak to reach and warm the four extremities. In this case, the counterflow cold is much more severe. The cold surpasses the elbows and knees, and is accompanied by symptoms of general yang deficiency and yin excess, as well as, a thin, impalpable pulse. The type of counterflow cold that is indicated by Dāng Guī Sì Nì Tāng is due to blood deficiency and pathogenic cold invasion, where the accumulation of cold blocks the vessels and causes poor blood circulation. In this case pathogenic cold invades the channels rather than the zang-organs, so the degree of counterflow cold is less serious than which is found in Sì Nì Tāng patterns. In addition, the limbs may also have pain. In conclusion, the medicinal applications and therapeutic functions of the three formulas are different from each other. As Zhou Yang-jun said, “Sì Nì Tāng is mainly used to restore yang to rescue from counterflow. Sì Nì Săn is mainly used to harmonize the internal and external. Dāng Guī Sì Nì Tāng is mainly used to nourish blood and unblock channels.” [4] (Complete Treatise on Summerheat Disease and Epidemic Disease, Wēn Rè Shŭ Yì Quán Shū, 温热暑疫全书)

Case Studies 1. Raynaud’s syndrome Wang, was a 37-year-old female. For years, the color of her fingers would change when it was cold, and her toes would get cold as well. She was diagnosed with Raynaud’s syndrome in a hospital. The symptoms mentioned above occurred frequently during the past month, so she came to visit our hospital. The signs and symptoms included dark, swollen fingers, thick nails, cracks in the index fingers, and cold hands and feet with pale

skin. Her radial artery and dorsal pedal artery beat normally, and the cold water test was positive. She often had vertigo and dizziness, palpitations, insomnia, aversion to cold, cold limbs, pale, sallow complexion, a thin, white tongue coating, a deep, thin pulse, and late menstruation with scanty, light colored blood. Her condition resulted from congenital blood deficiency with cold invasion causing poor blood circulation. Dāng Guī Sì Nì Tāng was applied to nourish the blood, unblock the blood vessels, warm yang, and dispel cold. The prescription was composed of dāng guī 15 g, guì zhī 10 g, sháo yào 10 g, xì xīn 3 g, gān căo 6 g, dà zăo 6 g, and huáng qí 15 g. After taking forty doses, the above symptoms did not recur even in the cold of winter, and the menstruation was normal. After taking another fourteen doses, the temperature of her skin returned to normal, and there was no aversion to cold. The patient was ordered to take the decoction intermittently in order to consolidate the effect. She had no relapse.1 Comments: The color of her fingers changed when they got cold and cold feet indicated cold accumulation in the channels. She had vertigo and dizziness, palpitations, insomnia, aversion to cold, cold limbs, pale sallow complexion, thin white tongue coating, deep thin pulse, and late menstruation with scanty light colored blood. These symptoms perfectly match the pattern of blood deficiency and cold accumulation in the channels treated by Dāng Guī Jiàn Zhōng Tāng. Hence, Dāng Guī Jiàn Zhōng Tāng was applied to warm yang, dispel cold, nourish blood, and unblock blood vessels. 2. Cold and painful limbs Wu, a 46-year-old female clothing factory worker, had painful knees for over ten years and painful lower legs in recent years. The pain was worse at night and was accompanied with occasional spasms and cold hands and feet.

Since the medication she was taking was not helping, she had two cats that she used to warm her knees in order to release the pain so she could sleep at night. Her symptoms and signs included a pale complexion and lips, a tongue body that was pale in color and dark in texture, and a pulse that was deep and thin. Her condition was differentiated as blood deficiency and cold accumulation. Dāng Guī Sì Nì Tāng was applied composed of dāng guī 18 g, guì zhī 12 g, bái sháo (processed with wine) 18 g, xì xīn 3 g, mù tōng 6 g, zhì gān căo 6 g, and dà zăo 7 pieces. After taking seven doses, her pain was mostly relieved, and her lower limbs and palms turned warm. After taking another fourteen doses, she did not need her cats to keep her legs warm any more.2 Comments: This patient had chronic cold pain in her joints. It was a chronic problem with enduring pain that would be released by warmth. According to her pale complexion and lips, the tongue and pulse manifestation, the pathogenesis was blood deficiency and cold accumulation blocking the channels; therefore, Dāng Guī Sì Nì Tāng was the appropriate formula.

Yáng Hé Tāng 阳和汤Harmonious Yang Decoction Source Text Life-Saving Manual of Diagnosis and Treatment of External Diseases (Wài Kē Zhèng Zhì Quán Shēng Jí, 外科证治全⽣集)

Formula Ingredients

1 Chen Shu-chang. Two Cases of Peripheral Vascular Disease 周围⾎管病治验2例. Journal of Traditional Chinese Medicine. 1987; (5): 30. 2 Pei Yong-qing. 50 Theories Clinical Practice of Treatise on Cold Damage 伤寒论临床应⽤五 ⼗论. Beijing: Xueyuan Press; 2004. p. 226.

Preparation and Administration Prepare as a decoction.

Formula Indications This formula is indicated for yin carbuncles. For example, a deeprooted abscess attached to the bone (suppurative osteomyelitis), sloughing deep-rooted abscess (digital gangrene), multiple abscesses, phlegm nodules, and arthroncus of the knee due to patterns of yin-cold. The affected area will

have diffuse swelling without discoloration of the skin, aching pain without fever, lack of thirst, a pale tongue body with a white coating, and a deep, thin pulse or slow, thin pulse.

Analysis of Fundamental Pattern Pathogenesis Yin carbuncles are most often related to congenital yang deficiency and insufficient nutrient blood causing an accumulation of cold and phlegm stagnation blocking muscles, tendons, bones, and blood vessels. Due to the nature of yin and cold, the local swelling is diffuse with no discoloration, there is aching pain but without fever, and there may be a general pattern of deficiency cold. In addition, the tongue is pale with a white coating, and a deep, thin pulse, which are also signs of deficient cold. The treatment is to warm yang, reinforce blood, disperse cold, and unblock stagnation.

Formula Actions Warms yang and reinforces blood, disperses cold and unblocks stagnation.

Formula analysis

Unique Combination Features This formula warms yang while it supplements the blood, removes phlegm, and unblocks the collaterals. This combination makes it possible to tonify the deficient yang and blood, and remove the cold and phlegm simultaneously. The treatment principle for treating yin carbuncles is similar to the warm spring sun shining through the earth, dissipating the darkness, and spreading sunshine everywhere. Therefore this formula is named as Yáng Hé Tāng.

Formula Applications 1. Essential pattern differentiation

Yáng Hé Tāng is a commonly used for yin carbuncles. This clinical pattern is marked by:

● the affected area has diffuse swelling without skin discoloration ● aching pain without fever 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of yin-cold accumulation: bone tuberculosis, peritoneal tuberculosis, chronic osteomyelitis, periostitis, chronic lymphnoditis, rheumatoid arthritis, thromboangitis obliterans, and deep abscess. 4. Cautions and contraindications In this formula, shú dì huáng is used at a large dose while má huáng is used at a small one. It is prohibited for ulcers due to patterns of excess yang that are red, swollen, painful, and a fever. In addition it should not be used for fevers due to yin deficiency or perforated ulcer. Ma Pei-zhi said, “it is amazing to treat a yin pattern with this formula following the correct method. Breast carcinoma is definitely excluded. Yin deficiency with fever or perforated ulcer is also forbidden. ” [5] (Revised Life-Saving Manual of Diagnosis and Treatment of External Diseases, Chóng Jiào Wài Kē Zhèng Zhì Quán Shēng Jí, 重校外科证治全⽣集)

Associated Formulas Xiăo Jīn Dān (Minor Metal Elixir , ⼩⾦丹) [Source] Life-Saving Manual of Diagnosis and Treatment of External Diseases (Wài Kē Zhèng Zhì Quán Shēng Jí, 外科证治全⽣集) [Ingredients]

Grind the above medicinals into powder, each of them is 1 liang and 5 qian (150 g).

Grind into powder, each of them is dosed at 7 qian 5 fen (75 g).

Add sticky rice 1 liang and 2 qian (120 g), mix with all the medicinal above, make 250 pills. [Actions] Dissolves phlegm, removes dampness, removes stasis, and dredges the collaterals. [Applicable Patterns] Patterns of cold dampness, phlegm, and stasis. Symptoms include: multiple abscesses, phlegm nodules, scrofula, carcinoma of the breast, hard and painful lumps.

In the original classic, Xiăo Jīn Dān is commonly used with Yáng Hé Tāng simultaneously or alternatively. This formula is stronger than Yáng Hé Tāng and is only applied to people with a strong constitution, and is prohibited to use for those who are weak or pregnant.

Case Studies 1. Cerebral furuncle My friend, Zhou Mu-lian, had suffered with early stage cerebral furuncle. I found that it was a yin pattern, and prescribed Yáng Hé Tāng. Since he had not defecated in the past five days, I was hesitated to prescribe Yáng Hé Tāng suspecting that there was heat accumulation. But the effect of Yáng Hé Tāng surprised me because the next morning he could easily move and turn his neck and had a good bowel movement. From this case, I realized that blocked defecation was due to cold.1 Comments: The early-stage cerebral furuncle and constipation in this case was caused by cold accumulation. Since the pattern matched Yáng Hé Tāng perfectly, it was used to warm yang, expel cold, and dredge stagnation. It not only treated the cerebral furuncle caused by yin-cold, but also treated the constipation due to cold accumulation. 2. Polycystic ovary syndrome A 28-year-old female had her initial visit on September 3rd, 2001. She had been infertile for five years after she married. She suffered menopause for one year, she was overweight, had heavy body hair, and a single-phased BBT. A B-ultrasound examination showed that her uterus was 48mm×28mm×39mm, and her ovaries were enlarged bilaterally: the left ovary was 45mm×22mm and the right one was 42mm×28mm, and her follicles were expanded. She was diagnosed with polycystic ovary

syndrome. She had her first period when she was 15 years old and her menstrual cycle was 30 to 45 days. Occasionally her menstruation would occur two or three months at a time. However, her menstruation stopped last July, and she put on a lot of weight. 1 Cao Yin-fu. Records of Experiments with Classical Formulas 经⽅实验录. Shanghai: Shanghai Science and Technology Press; 1979. p. 240.

On her visit her condition included a lusterless complexion, occasional vertigo, mental fatigue, desire to sleep, aching waist, cold limbs, profuse and clear leucorrhea, loose stool, a pale tongue body with a white coating, and a deep, thin, slow pulse. Her condition was differentiated as phlegm blocking the ovary and yang deficiency failing to nourish the yin essence, which was unable to release causing menopause and infertility. The treatment method was to warm yang, supplement essence, dissolve phlegm, and unblock stasis. A modification of Yáng Hé Tāng was prescribed composed of shú dì huáng 30 g, lù jiăo jiāo (melted, take infused) 15 g, ròu guì (added later) 10 g, bái jiè zĭ 12 g, má huáng 6 g, gān jiāng 10 g, zhì gān căo 6 g, fú líng 15 g, zào jiăo cì 15 g, xiān líng pí 15 g, é zhú 15 g, and chōng wèi zĭ 15 g. After taking this decoction for three months, there was first transparent leucorrhea, followed by normal menstruation, and the BBT curve was in biphase for few months. Another B-ultrasound examination showed that both ovaries were then normal, and she got pregnant soon thereafter.1 Comments: Infertile five years after marriage, menopause for one year, lusterless complexion, occasional vertigo, mental fatigue, desire to sleep, aching waist, cold limbs, profuse clear leucorrhea, loose stools, a pale tongue body with a white coating, and a deep, thin, slow pulse are all manifestations of yang deficiency, cold accumulation, yin essence deficiency, phlegm obstruction, and blood stagnation. The treatment was a modified Yáng Hé Tāng used to warm yang, supplement essence, remove

phlegm, and unblock stasis. Fú líng was used to percolate dampness and disperse phlegm, zào jiăo cì was used to resolve phlegm and unblock the collaterals, xiān líng pí and chōng wèi zĭ were used to supplement the liver and spleen, and é zhú was used to activate the blood and remove stasis.

Summary There are seven formulas within the formulas that warm the interior chapter:

● formulas that warm the center and dispel cold ● formulas that restore yang and rescue counterflow ● formulas that warm the channels and expel cold. 1. Formulas that warm the center and dispel cold Formulas that warm the center and dispel cold are indicated for patterns of yang deficiency in the middle jiao. Lĭ Zhōng Wán effectively warms the middle jiao, expels cold, reinforces qi, and strengthens the spleen. It is a basic formula used to treat patterns of yang deficiency in the middle jiao, as well as, dysfunction of the middle jiao’s ascending and descending function causing abdominal pain, vomiting, and diarrhea. It can also be used as a decoction. Xiăo Jiàn Zhōng Tāng has the effects of warming the middle jiao to expel cold, reinforcing deficiency to relieve pain, and is used for severe cold and pain in the abdomen due to yang deficiency in the middle jiao and disharmony of the liver and spleen. Wú Zhū Yú Tāng is mainly used to descend the qi of the liver and stomach with warming medicinals. It can also strengthen the middle jiao when it is deficient. It is often used to treat deficiency-cold in the liver and stomach resulting counterflow of turbid yin manifested as vomiting and headache.

2. Fromulas that restore yang and rescue counterflow Formulas that restore yang and rescue counterflow are indicated for urgent and severe cases such as, heart and kidney yang weakness, internal cold excess, and yang collapse. Sì Nì Tāng is the basic formula used to recuperate yang and rescue collapse, particularly for the cases of excessive cold in the interior with exhaustion of yang manifested as counterflow cold of the hands and feet, debilitated spirit, desire to sleep, and a thin, feeble pulse. Huí Yáng Jiù Jí Tāng is the basic formula used to recuperate yang, rescue collapse, and rectify qi to generate the pulse. Shè xiāng and wŭ wèi zĭ are used in this formula as a combination that can diffuse and astringe simultaneously. The diffusing and astringing methods are both opposite and complementary to each other. Huí Yáng Jiù Jí Tāng is indicated for patterns of cold damaging the three yin channels directly and yang collapse. 3. Formulas that warm the channels and expel cold 1 Liu Xia-li. Ingenious Uses of Yáng Hé Tāng 阳和汤新⽤举隅. Chinese Journal of Clinical Practice. 2003; (8): 724.

Formulas that warm the channels and expel cold are indicated for yang and blood deficiency with cold accumulated in the channels, characterized by counterflow cold of the hands and feet and yin carbuncle. Dāng Guī Sì Nì Tāng can expel cold from the channels, nourish blood, and unblock the vessels. It is often used to treat counterflow cold of the hands and feet or general pain due to blood deficiency and cold accumulation. Yáng Hé Tāng is quite commonly used to treat yin carbuncle by warming yang, nourishing blood, dissipating cold, and unblocking obstruction.

Questions

1.Define the definition, categories, indications, and cautions of the formulas that warm the interior. 2.State the indications and explain the rationale of the medicinal combinations used in Lĭ Zhōng Wán. 3.State the differences of the treatment principles, compositions, and indications between Xiăo Jiàn Zhōng Tāng and Guì Zhī Tāng. 4.Explain the effect characteristics and indications of Wú Zhū Yú Tāng. 5.Describe the effects of the medicinals and indications of Sì Nì Tāng. 6.List the differences of the therapeutic effects, pathogenesis, and indications between Dāng Guī Sì Nì Tāng and Sì Nì Tāng. 7.Describe the indications and explain the rationale of the medicinal combinations used in Yáng Hé Tāng.

Endnotes: [1] 阳⽓者，精则养神，柔则养筋 [2] 分温再服，其脉即出者愈 [3] 服汤，脉暴出者死，微续者⽣ [4] 四逆汤全在回阳起见，四逆散全在和解表⾥起见，当归四逆汤 全在养⾎通脉起见 [5] 此⽅治阴证，无出其右，⽤之得当，应⼿⽽愈。乳岩万不可 ⽤，阴虚有热及破溃⽇久者，不可沾唇

CHAPTER 6 Supplementing and Boosting Formulas Supplementing and boosting formulas are mainly composed of medicinals that supplement and boost the body and its vital substances. As they supplement and boost the body’s qi, blood, yin, and yang, they are primarily intended to treat various deficiency syndromes. The compositions of the formulas in this chapter have been guided by the classics, adhering to principles such as, “when there is deficiency, treat it with supplementation”[1], “treat deficiency with supplementation”[2], and “treat physical insufficiency by warming in order to nourish the qi”[3], “essence insufficiency should be treated with thick-flavored tonics”[4]. Supplementing and boosting formulas pertain to the “supplementing method” of the eight treatment methods. There are many circumstances that lead to deficiency. However, the various deficiencies originate from either prenatal insufficiency or postnatal disharmony (including impairment from improper food intake, inappropriate physical labor, emotional fluctuation, or remaining disharmony after a disease). Deficiencies of the five zang-organs involve qi, blood, yin, and yang. They result in six patterns of deficiency: qi deficiency, blood deficiency, qi and blood deficiency, yin deficiency, yang deficiency, or deficiency of both yin and yang. Thereby, formulas in this chapter are divided into the following six categories:

● formulas that supplement qi

● formulas that supplement blood ● formulas that supplement both qi and the blood ● formulas that supplement yin ● formulas that supplement yang ● formulas that supplement both yin and yang The methods of supplementing and boosting qi, blood, yin, and yang are all different. However, because the vital substances are closely interrelated with each other, one cannot isolate their individual treatments. Therefore, when prescribing formulas, it is imperative to maintain a comprehensive view while emphasizing the desired therapeutic target. Supplement the qi when it is deficient. Supplement the blood when it is deficient. Although the therapeutic emphasis is different for qi and blood, they cannot be truly separated as they ultimately depend on each other. Therefore, the qi-supplementing and blood-supplementing methods are always used simultaneously. The Treatise on the Spleen and Stomach (Pí Wèi Lùn, 脾胃论) explains that blood cannot generate from itself, and it requires assistance from yang qi-supplementing medicinals. It is recorded in the Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温病 条辨) that blood is enriched automatically when qi is supplemented. For this reason, it is suggested to add qi-supplementing medicinals to bloodsupplementing formulas in order to promote blood generation and transformation. This is especially important when blood deficiency has been caused by a sudden loss of blood. In this case, qi-supplementation should be emphasized in order to better generate blood and rescue the patient from desertion. When supplementing the qi, it is suggested to choose qisupplementing medicinals as the primary ingredients. Accompany them with some bloodsupplementing medicinals as deemed necessary. Be careful not to

use too much because they may hamper the spleen and stomach with their yin properties. For dual deficiency of both qi and blood, it is advised to tonify qi and blood at the same time. The same principle can be applied regarding the supplementation of yin and yang. As yin and yang are rooted in each other, one cannot grow without the existence of the other. It is noted in The Classified Classic (Lèi Jīng, 类 经) that “one who is good at supplementing yang will seek yang within yin, so that yang will be generated easily with the help of yin; and vice versa, yin will be generated and transformed better by seeking yin within yang”[5]. Therefore, formulas used for treating yang deficient patients contain yinsupplementing medicinals in addition to the yangsupplementing medicinals. Yang is generated better when yin-supplementing medicinals are used alongside them. Additionally, they neutralize the warm-dry properties of the yang medicinals, which allows yang to be generated without damaging fluids. Likewise, yin-supplementing formulas contain yang-supplementing medicinals in addition to the yin-supplementing medicinals. Here, the yangsupplementing medicinals help kindle the thick yin-supplementing medicinals. This prevents qi stagnation by providing warmth and promoting the transformation of their thick qi. For deficiency of both yin and yang, both of them should be supplemented without any doubt. When supplementing the five zang-organs, there is both a direct supplement method and an indirect supplement method. The Classic of Difficult Issues - 14th Difficult Issue (Nàn Jīng-Shí Sì Nàn, 难经·⼗四难) records, “when the lung is impaired, the treatment should be to boost its qi; when the kidney is injured, the treatment should be to boost essence.” [6] This statement describes the direct supplement method as supplementing the actual deficient zang-organ. The indirect supplement method is to supplement the mother of the deficient organ according to the mutual

promotion theory of the zang-fu organs. For example, supplement the spleen in the case of lung qi deficiency (bank up earth to generate metal), supplement mìng mén in case of spleen yang deficiency (supplement fire and engender earth), and supplement the kidney for liver yin deficiency (nourish water to moisten wood). A few points must be kept in mind while prescribing supplementing and boosting formulas. First, one must accurately discern the location of the deficiency (qi, blood, yin, or yang) and supplement the deficiency according to the theory of mutual promotion of the zang-fu organs. Second, one must distinguish between true and false manifestations of deficiency and excess. The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全书) records, “excess may manifest in the case of extreme deficiency; deficiency may manifest in the case of extreme excess.” [7] The former refers to true deficiency with false excess and if it is mistakenly purged, the true deficiency will become worse. Vice versa, if supplementation is applied to the latter, the real excess will be aggravated. Third, one should keep the function of the spleen-stomach in consideration, since supplements are easy to incur qi stagnation. If a patient suffers spleen and stomach deficiency, one should include medicinals that regulate the qi and awaken the spleen in order to assist the transportation and transformation function of the spleenstomach. Finally, one needs to pay attention to the preparation and administration methods of these formulas. To ensure efficacy, they typically require a long decoction at a low temperature. Supplementing and boosting formulas are best taken on an empty stomach or before meals. It should be noted that all of these rules do not apply in emergency cases.

Section 1 Qi-Supplementing Formulas

The formulas in this section apply to patterns of spleen-lung qi deficiency. The signs and symptoms of which include fatigue of the limbs, lack of strength, weak breathing, no desire to speak, a faint, low voice, shortness of breath induced by even slight movement, pale and lusterless facial complexion, poor appetite, thin unformed stool (a type of “loose stool”), a pale tongue with white coating, and a deficient, weak pulse. In severe cases, there may be deficiency heat, spontaneous sweating, and rectal or uterine prolapse. Commonly used chief medicinals used in the qisupplementing formulas include rén shēn, dăng shēn, huáng qí, bái zhú, and gān căo. Medicinals such as fú líng and yì yĭ rén, that promote urination and percolate dampness, are always included when there is concurrent dampness accumulation. For concurrent qi stagnation, qi-moving medicinals such as mù xiāng and chén pí are added. For concurrent prolapse of organs, caused by qi sinking due to deficiency, medicinals that rise upwards such as shēng má and chái hú are added. Typical qi-supplementing formulas include Sì Jūn Zĭ Tāng, Shēn Líng Bái Zhú Săn, Bŭ Zhōng Yì Qì Tāng, Shēng Mài Săn, Yù Píng Fēng Săn, and Wán Dài Tāng.

Sì Jūn Zĭ Tāng 四君⼦汤Four Gentlemen Decoction Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind all of the medicinals into a thin powder. Decoct 15 g together with 1 zhan of water until 30% of the water has vaporized. Take it orally whenever necessary. A little salt may be added to the powdered medicinals, but it is not necessary. (Modern use: decoct with water.)

Formula Indications Sì Jūn Zĭ Tāng is indicated for patterns of spleen-stomach qi deficiency. Clinical manifestations include a pale, lusterless facial complexion, a faint, low voice, shortness of breath, and thin, unformed stool. The tongue is pale with a white coating. The pulse is deficient and weak.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by spleen-stomach qi deficiency that hinders the transportation and transformation process. The spleen and stomach are the foundations of the postnatal constitution and the source of qi and blood production. When they become deficient there is not enough energy to support food digestion and absorption, which causes there to be less food intake. Internal dampturbidity may follow spleen-stomach deficiency, which leads to thin, unformed stools. Since the spleen governs the muscles and limbs, and the nutrients transformed by a deficient spleen are far from enough, patients may lack strength. When this deficiency affects the qi and blood production, patients may develop a pale complexion because there is

not enough blood going upward to nourish the face. The spleen is the mother to the lung, so lung qi may also become impaired and cause shortness of breath and a faint, low voice. The tongue and pulse signs all indicate qi deficiency. In this condition, the treatment is to supplement and boost the spleen-stomach qi in order to re-establish normal transportation and transformation.

Formula Actions Boosts qi and fortifies the spleen.

Formula Analysis

Unique Combination Features This formula supplements the qi, but does not cause stagnation; it warms, but does not cause dryness.

Formula Applications 1. Essential pattern differentiation

Sì Jūn Zĭ Tāng is a basic formula used to supplement qi, and is commonly used to treat patterns of spleen-stomach deficiency. Many formulas developed in later generations, that supplement the spleen and boost qi, are derived from it. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used to treat chronic gastritis, gastric ulcer, and duodenal ulcer when the patient shows signs of spleen qi deficiency.

Associated Formulas Yì Gōng Săn (Special Achievement Powder, 异功散) [Source] Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀) [Ingredients]

[Preparation and Administration]

Prepare it as a decoction. [Actions] Boosts qi and fortifies the spleen, moves qi and resolves food stagnation. [Applicable Patterns] Spleen-stomach qi deficiency with qi stagnation. Liù Jūn Zĭ Tāng (Six Gentlemen Decoction, 六君⼦汤) [Source] True Biography of Medicine (Yī Xué Zhèng Zhuàn, 医学正传) [Ingredients]

[Preparation and Administration] Prepare it as a decoction with 3 pieces of shēng jiāng and 2 pieces of dà zăo. [Actions] Boosts qi and fortifies the spleen, dries dampness, and dissolves phlegm. [Applicable Patterns] Spleen-stomach qi deficiency with concurrent phlegm-damp. Xiāng Shā Liù Jūn Zĭ Tāng (Costusroot and Amomum Six Gentlemen Decoction, ⾹砂六君⼦汤) [Source]

Comments on Ancient and Modern Famous Case Records (Gŭ Jīn Míng Yī Fāng Lùn, 古今名医⽅论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction with 2 qian (6 g) of shēng jiāng. [Actions] Boosts qi, dissolves phlegm, moves qi, and warms the center. [Applicable Patterns] Spleen-stomach qi deficiency with phlegm obstruction and qi stagnation. Yì Gōng Săn, Liù Jūn Zĭ Tāng, and Xiāng Shā Liù Jūn Zĭ Tāng are all modifications from Sì Jūn Zĭ Tāng. Adding chén pí makes Yì Gōng Săn, designed to address concurrent qi stagnation by moving qi and resolving [food] stagnation. Adding bàn xià and chén pí makes Liù Jūn Zĭ Tāng, which treats concurrent qi counterflow or damp-phlegm patterns by drying dampness and dissolving phlegm. Adding bàn xià, chén pí, mù xiāng, and shā rén makes Xiāng Shā Liù Jūn Zĭ Tāng, which treats concurrent phlegm obstruction and qi stagnation by moving qi and warming the center. These three formulas all combine qi-supplementing, qi-moving, and phlegmdissolving medicinals together. They boost qi but do not cause qi stagnation and facilitate transportation and transformation because they dissolve phlegm-dampness. They are good for spleen-stomach qi deficiency accompanied by qi stagnation and phlegm-damp obstruction.

Comparison & Contrast Sì Jūn Zĭ Tāng vs. Lĭ Zhōng Wán

Case Studies 1. Food stagnation due to spleen deficiency A child suffering with frequent food stagnation was prescribed many Chinese digestants that were not effective. One day this child was brought to a new doctor who explained, “Your condition is caused by spleen-stomach qi deficiency that fails to transport and transform the food, therefore, the treatment should be to regulate and supplement spleen and stomach and not promote digestion and guide out food stagnation. In this condition, it will only aggravate the deficiency and in return, worsen the food stagnation.” The child had felt a mass forming in the abdomen manifesting with alternating chills and fever, tidal fever, poor appetite, thirst, and unformed stools. It was suggested that he take Sì Jūn Zĭ Tāng. After that, the appetite

gradually increased. He was then prescribed Bŭ Zhōng Yì Qì Tāng, which finally cured the disease.1 Comments: The spleen-stomach failed to transport and transform the food, due to qi deficiency, and lead to food stagnation. The spleen qi was too deficient for the attacking method; therefore, the necessary treatment was to reinforce the spleen qi in order to foster the root. Once the spleen qi recovered, the food stagnation would disappear by itself. This is called “treat food stagnation automatically without the use of digestants”[8]. 2. Senile constipation 1 Jiang Guan, Wei Zhi-xiu. Classified Case Records of Famous Physicians (continued edition) 名 医类案（正续编）. Beijing: China Press of Traditional Chinese Medicine; 1996. p. 804-805.

Li, a 72-year-old man, was seen on June 25th, 2003. His chief complaint was constipation for five years. He had bowel movements once or twice per week with hard stools that were difficult to pass. He managed by using aloe capsules or a glycerine enema to ease the process. At the time of his visit, he appeared thin and lusterless complaining of shortness of breath, lack of strength, poor appetite, occasional vomiting, nausea, and dry stools that were difficult to pass. The tongue was swollen and tender with a thin, white coating. The pulse was deep and weak. His condition was diagnosed as center qi deficiency and insufficiency of body fluids. Therefore, the treatment was to fortify the spleen, boost qi, nourish yin, and promote fluid production. Modified Sì Jūn Zĭ Tāng was prescribed. The prescription was dăng shēn 25 g, raw bái zhú 25 g, xuán shēn 25 g, mài dōng 25 g, fú líng 15 g, dry-fried bīng láng 15 g, băi zĭ rén 15 g, huáng qí 30 g, hòu pò 10 g, and zhì gān căo 7 g. He was instructed to decoct it with water and take one dose per day. After seven days the bowel movements became smooth. After fourteen days they normalized without any symptoms. He was instructed not to take purgatives, but to increase the fruit and vegetables in his diet. It was

suggested that he try to have a bowel movement at a fixed time each morning. The patient followed the advice and the problem resolved without reoccurrence up until now.1 Comments: Constipation is a disease that relates with not only the large intestine but also with the spleen, stomach, lung, liver, and kidney. The elderly easily suffer with deficiency of the qi and body fluid, especially after a disease or if they have a generally weak constitution. The spleen is in charge of food transportation and transformation. A deficient spleen fails to push the large intestine and insufficient blood or fluids fail to moisten the bowels. Together this leads to constipation. As is seen in the case above, it is a complex pattern of mixed deficiency and excess with deficiency as the root. The prescription used was to primarily supplement the spleen qi and, secondarily, to circulate the qi. The raw bái zhú contained in Sì Jūn Zĭ Tāng is rich in fluids, so it is helpful to dredge the bowels without harming zheng qi. Huáng qí supplements the center and boosts qi. Mài dōng and xuán shēn can both enrich yin and moisten dryness. Hòu pò and dry-fried bīng láng both move qi and promote bowel movement. This is the method called “treating the blocked by blocking.”

Shēn Líng Bái Zhú Săn 参苓⽩术散Ginseng, Poria and Atractylodes Macrocephala Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

1 Jing Jian-zhong. 150 Medical Cases on Senile Habitual Constipation by Qi-Supplementing and Spleen-Fortifying Methods 益⽓健脾法治疗⽼年习惯性便秘150例. Shaanxi Journal of Traditional Chinese Medicine. 2005; 26: 9.

Preparation and Administration Grind the medicinals into a thin powder. Take 6 g each time with Dà Zăo Tāng (Jujube Decoction,⼤枣汤). The proper dosage for children is related to their age. (Modern preparation: prepare as a decoction, reduce the dose of each medicinal by adhering to the ratio from the original formula.)

Formula Indications

Shēn Líng Bái Zhú Săn is indicated for patterns of spleen deficiency with excessive dampness accumulation marked by epigastric bloating or stuffiness, borborygmus, diarrhea, lack of strength in the four limbs, thin body, and lusterless yellow facial complexion. The tongue is pale with a white, greasy coating and the pulse is moderate and deficient.

Analysis of Fundamental Pattern Pathogenesis The stomach governs the reception of food, while the spleen governs its transportation and transformation. If the spleen and stomach are deficient, there is not enough energy to support the reception of food; therefore, the food ingested can hardly be digested. A deficient stomach-spleen can barely separate the clear from the turbid, leading to borborygmus and diarrhea. Excessive dampness accumulates in the middle jiao. This causes the qi to move in disorder resulting in chest and epigastric bloating and stuffiness. When the production of qi and blood is reduced, it fails to provide enough nutrition to the body. The four limbs lack strength, weight is lost, and the facial complexion becomes withered-yellow. So the necessary treatment is to supplement and boost the spleen-stomach and percolate dampness.

Formula Actions Boosts qi and fortifies the spleen, drains dampness and arrests diarrhea.

Formula Analysis

Continued

Unique Combination Features This formula combines shā rén, a qi-moving medicinal, with a large number of medicinals that supplement the qi. It integrates the astringent lián zĭ with aromatic medicinals that dry dampness or bland medicinals that drain dampness. This allows for it to properly supplement and drain dampness in a balanced manner. All the medicinals in this formula have a mild nature.

They are warm, but not drying. They supplement without causing stagnation. This formula treats the lung and spleen simultaneously. According to the five-phase theory, it is a method referred to as “banking up earth to generate metal.” [9]

Further Clarification There are three reasons for the use of jié gĕng. First, it opens the lung qi so that the essence can spread all over the body. Second, it can free and regulate the water passageways. An open and smooth waterway is good for the elimination of dampness. Third, it carries all of the spleensupplements upwards to the lung, so that essence transformed by spleen can be sent to the lung, referred to as “banking up earth to generate metal.” [9]

Formula Applications 1. Essential pattern differentiation This formula has a mild nature. It is warm, but not dry. Besides the basic spleen-stomach qi deficiency symptoms, the key points that differentiate this pattern include diarrhea, white greasy tongue coating, and a deficient, moderate pulse. 2. Modifications

3. Modern applications

Shēn Líng Bái Zhú Săn is frequently used for chronic gastritis or enteritis, anemia, chronic bronchitis, nephritis, and leukorrhea that manifest with spleen deficiency and excessive dampness signs.

Associated Formulas Qī Wèi Bái Zhú Săn (Seven Ingredients Atractylodes Macrocephalae Powder, 七味⽩术散) [Source] Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Fortifies the spleen, boosts qi, harmonizes the stomach, and promotes fluid production. [Applicable Patterns] Spleen-stomach weakness. Symptoms include: fluid deficiency and internal heat manifesting vomiting, diarrhea, hot sensation, and extreme thirst.

Comparison & Contrast

Shēn Líng Bái Zhú Săn vs. Sì Jūn Zĭ Tāng

Case Studies 1. Menstrual diarrhea A lady was suffering from frequent diarrhea for three days during her menstrual period. She was then brought to the doctor. Her pulses were soggy and weak on both sides. The doctor explained, “This all comes from spleen deficiency. The spleen governs the blood and is closely related with the transportation and transformation of water-dampness. Menstrual blood, which flows from the sea of blood, is closely related with the spleen. Therefore, spleen blood will be deficient every time the period comes. Diarrhea occurs when the spleen is too deficient to transform the dampness.” She was instructed to take two qian of Shēn Líng Bái Zhú Săn, with

porridge, two to three times per day. She followed this advice and after a month or so, the problem was gone.1 Comments: If a person is spleen deficient, s/he will easily suffer with spleen deficiency. Spleen deficiency is aggravated during the period when the qi and blood are flowing into the chong mai and ren mai. When waterdampness cannot be transformed by the spleen, it flows downward into the large intestine and cause diarrhea. Therefore, the treatment should be to supplement the spleen, boost qi, eliminate dampness, and arrest diarrhea, which corresponded to the indications of Shēn Líng Bái Zhú Săn. Taking it together with porridge improved the absorption of the spleen-stomach. The prescription matched the disease pattern therefore the menstrual diarrhea was controlled. 2. Pediatric diarrhea Wang, a 2-year-old boy, was seen on Aug 24th, 2003 for the first time. He had continual watery diarrhea for three days. Sometimes he had sixteen bowel movements a day that were accompanied with vomiting, fever (37.8°C), thirst, scanty urine, lusterless facial complexion, cold extremities, poor elasticity of the skin, and sunken eyes. The tongue was pale with no coating. Fat globules (+++) were found in a stool examination. He was diagnosed with deficiency of both spleen and kidney and damage to both yin and yang. The treatment needed to supplement and boost the spleen and kidney, drain dampness, and arrest diarrhea. The prescription was shān yào 10 g, yì yĭ rén 10 g, biăn dòu (dry-fried) 10 g, zé xiè 10 g, băn lán gēn 10 g, dăng shēn 6 g, yún líng 6 g, bái zhú 6 g, gé gēn 6 g, lián zĭ ròu 6 g, huò xiāng 5 g, shēng má 5 g, shā rén (added later) 3 g, and gān căo 3 g. Decoct one dose with water until 150 ml concentration is obtained. Split each dose into three to five equal parts that are taken warm over the course of one day.

After taking the formula for two days, the fever receded, the vomiting and diarrhea stopped, and he was cured. The child had no reoccurrence since then.2 Comments: The primary pathomechanism of diarrhea is spleen deficiency and excessive dampness. However, spleen deficiency takes the precedence. Therefore, regulating and rectifying the spleen and stomach is the major treatment principle. In this prescription, dăng shēn, bái zhú, shān yào and shā rén are used to supplement the spleen and boost qi, warm the center, and arrest diarrhea. Yún líng, zé xiè, yì yĭ rén, and dry-fried biăn dòu are used to drain dampness, consolidate the kidney, and arrest diarrhea. Băn lán gēn and shēng má are used to clear heat and resolve toxins, raise yang, and lift the sunken. Gé gēn is used to promote fluid production in order to quench thirst, raise yang, and arrest diarrhea. Huò xiāng is an aromatic medicinal used to remove dampness, raise the clear, and direct the turbid downward. Gān căo is used to supplement the center, boost qi, and harmonize the actions of all the medicinals in a formula. Altogether, they work to boost the spleen, remove dampness, raise the clear, direct the turbid downward, clear heat, resolve toxins, astringe the intestines, and arrest diarrhea. The functions of this formula matched the disease mechanisms; therefore, it cured the acute pediatric diarrhea. 1 Yu Zhen. Comments on Ancient and Modern Case Records 古今医案按. Beijing: China Press of Traditional Chinese Medicine; 1997. p. 160. 2 Hua Gang. Treatment with Modified Shēn Líng Bái Zhú Săn for 68 Cases of Pediatric Diarrhea 参苓⽩术散加减治疗⼩⼉急性腹泻68例. Guangming Journal of Chinese Medicine. 2008; (23): 1953.

Bŭ Zhōng Yì Qì Tāng 补中益⽓汤CenterSupplementing and Qi-Boosting Decoction Source Text Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn, 内外伤辨惑论)

Formula Ingredients

Preparation and Administration In the original text, it was noted, “add 2 cups of water and boil until it is decocted into 1 cup. Take it while it is warm.” Modern administration: decoct with water. It can also be made into pills. Take 10 to 15 g each time, two to three times a day. Take the pills with warm boiled water or ginger soup.

Formula Indications

Bŭ Zhōng Yì Qì Tāng is indicated for two patterns. The first pattern is deficient or sunken spleen qi with reduced food intake, general sluggish sensation, weak breathing, lack of desire to speak, sallow-yellow facial complexion, and loose unformed stool. The tongue is pale and the pulse is deficient. It is also used for rectal prolapse, uterine prolapse, chronic diarrhea, and flooding and spotting (bēng lòu, 崩漏). The second pattern is objective or subjective fever due to qi deficiency manifested by a feverish sensation, spontaneous sweating, thirst with a desire for hot drinks, shortness of breath, and lack of strength. The tongue is pale and the pulse is deficient, big, and weak.

Analysis of Fundamental Pattern Pathogenesis The etiologies involved are an improper diet and exhaustion-fatigue (fatigue from overstrain). Pathogenic factors damage the spleen-stomach causing deficiency, which over time, lead to sinking of clear yang. The spleen-stomach is the generating source of ying, wei qi, qi, and blood. Reduced food intake, weak breathing, lack of desire to speak, loose, unformed stool, etc. are all signs of spleen-stomach deficiency. Rectal and uterine prolapse indicate spleen deficiency. The spleen governs the ascent of the clear and when it is deficient over a period of time will lead to center qi sinking. Feverish body and spontaneous sweating are caused by deficiency of qi, which fails to consolidate the exterior and floats (yang) to the external part of the body. The treatment principle should be to supplement spleen-stomach qi, and raise the sinking yang.

Formula Actions

Supplements the center and boosts qi; raises yang and lifts the sunken.

Formula Analysis

Unique Combination Features This formula places precedence on qi-supplementation over raising yang. In addition to supplementing qi, it also includes medicinals that nourish blood, addressing the yin-yang relationship—when yin arises, yang grows. Chén pí used in combination with a large group of boosting medicinals will render the group restorative without causing stagnation.

Further Clarification

The feverish body (fever) in this pattern is caused by qi deficiency rather than external contraction. Deficient spleen and stomach qi fails to ascend and descend normally. As a result, the clear yang sinks and spleen dampness flows downward. Long-term accumulation of yang qi in the lower jiao generates heat, which then stirs upward. Clarifying Doubts about Damage from Internal and External Causes teaches that to treat this kind of fever, “the only method is to supplement the center qi and raise yang with sweet-warm medicinals and to clear the fire with sweet-cold medicinals. This type of fever can only be relieved by warm medicinals. Bitter-cold medicinals should be prohibited for use at this moment, for they would do harm to the spleen-stomach. This is the reason for the development of Bŭ Zhōng Yì Qì Tāng.” [10] The sunken yang fails to rise and becomes stagnant. As such, it fails to spread to the exterior and causes fever. Sweet-warm medicinals boost qi and raise the yang so clear yang can return to its original place and allow the fever to automatically disappear. Therefore, Bŭ Zhōng Yì Qì Tāng is regarded as the representative formula to “clear heat with sweetwarm medicinals.” [11]

Formula Applications 1. Essential pattern differentiation Bŭ Zhōng Yì Qì Tāng is a representative formula used to boost qi, raise yang, and clear heat with sweet-warm medicinals. This clinical pattern is marked by:

2. Modifications

3. Modern applications Bŭ Zhōng Yì Qì Tāng is widely used to treat the following diseases caused by spleen-stomach qi deficiency or center qi sinking in terms of TCM: visceroptosis, chronic diarrhea, prolapse of organs (uterus, anus), myasthenia gravis (MG), chyluria, chronic hepatitis, urinary retention during pregnancy or the postpartum period, threatened miscarriage, profuse menstruation, drooping eyelid, and paralytic strabismus. 4. Cautions and contraindications This formula is prohibited for patients with yin-deficiency fever or excessive internal heat.

Associated Formulas Shēng Yáng Yì Wèi Tāng (Yang-Raising and Stomach-Boosting Decoction, 升阳益胃汤) [Source] Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn,内外伤辨惑论)

[Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Boosts qi and raises yang, clears heat and eliminates dampness. [Applicable Patterns] Fever due to damp constraint resulting from stomach-spleen qi deficiency. Symptoms include: general fatigue, somnolence, feeling heavy and pain in the limbs, bitter taste in the mouth, a dry tongue, inability to taste the flavors of food, indigestion, and irregular stools. Shēng Xiàn Tāng (Raising the Sinking Decoction, 升陷汤) [Source] Records of Chinese Medicine with Reference to Western Medicine (Yī Xué Zhōng Zhōng Cān Xī Lù, 医学衷中参西录) [Ingredients]

[Preparation and Administration]

Prepare it as a decoction. [Actions] Boosts qi and raises the sunken. [Applicable Patterns] Qi sinking. Symptoms include: shortness of breath, difficult inhalation, too weak to breath, and a deep, slow, faint and weak or irregular pulse. Jŭ Yuán Jiān (Original Qi Lifting Decoction, 举元煎) [Source] The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Boosts and raises qi. [Applicable Patterns] Qi sinking after long-term qi deficiency, blood flooding, blood desertion, or yang collapse pattern. These three associated formulas, as well as Bŭ Zhōng Yì Qì Tāng, are all used to supplement the spleen, boost qi, and raise and lift clear yang with

different medicinal combinations. The first associated formula, Shēng Yáng Yì Wèi Tāng contains the most ingredients of the four formulas. A large dosage of huáng qí is used, in combination with rén shēn, bái zhú, and gān căo, to supplement the qi and nourish the stomach. Chái hú, fáng fēng, qiāng huó, and dú huó raise and lift clear yang and eliminate wind and dampness. Bàn xià, chén pí, fú líng, zé xiè, and huáng lián eliminate dampness and clear heat. Bái sháo nourishes the ying and harmonizes the blood. It is used for longterm dampness stagnation that has transformed into heat due to spleen and lung qi deficiency. The second one, Shēng Xiàn Tāng, provides the raising and lifting methods from Bŭ Zhōng Yì Qì Tāng. One feature is that it uses a large amount of huáng qí, without rén shēn, bái zhú, or gān căo, in combination with chái hú and shēng má to raise the sunken yang. Zhī mŭ, cold and moistening, is used to restrict the warm nature of huáng qí, while jié gĕng is used to guide the other medicinals upwards to work with the lung. Overall, this formula is to treat severe lung qi sinking patterns. Rén shēn can be added for those with extreme lung and spleen deficiency and shān zhū yú can be added to astringe the scattering qi. The third formula, Jŭ Yuán Jiān, can be viewed as a simplified Bŭ Zhōng Yì Qì Tāng. It is indicated for lifethreatening patterns such as deficient, sunken qi or sudden profuse blood loss and qi collapse. Both rén shēn and huáng qí are used in a large amount and the remaining medicinal composition is simplified in order to emphasize the formula’s function to boost qi and rescue from desertion, raise yang, and raise the sunken.

Case Studies 1. Fever A patient presented with feverish body, heat in the palms, lack of strength, mental fatigue, diarrhea, and a soggy pulse. The doctor said that

these were signs of yin fire stirring upward due to sunken spleen yang. This was a clear indication for Bŭ Zhōng Yì Qì Tāng as it relieves fever with sweet-warm medicinals. Therefore, it was prescribed with the addition of biē jiă.1 Comments: This case was caused by yin fire stirring upward due to spleen deficiency. Therefore, the treatment principle was to relieve fever with sweet-warm medicinals. Bŭ Zhōng Yì Qì Tāng was used to supplement the center qi and raise yang. Biē jiă was used to supplement yin and clear heat. 2. Somnolence A 42-year-old man came to see the doctor on Aug 19, 2007 for the first time. His chief complaint was somnolence, lack of strength in the four limbs, and soreness of the waist and knees for about twenty days. Due to his busy schedule, the patient had overworked recently. He gradually developed mental fatigue, lack of strength in the four limbs, poor appetite, weak breathing, and reluctance to talk. Soon after, he felt soreness of the waist and knees and somnolence. He received western medicine treatment for ten days without a good result, so he sought traditional Chinese medicinal treatment in this hospital. The presenting signs and symptoms include mental fatigue, a pale complexion, weak breathing, and reluctance to talk. The treatment principle was to supplement the center and boost qi, warm the kidney, and raise yang. The prescription was a modified Bŭ Zhōng Yì Qì Tāng. The formula included raw huáng qí 30 g, dăng shēn 15 g, bái zhú (dry-fried) 12 g, dāng guī 10 g, chén pí 6 g, shēng má 8 g, chái hú 6 g, zhì gān căo 9 g, raw má huáng 3 g, xiān líng pí 12 g, shú fù zĭ 6 g, shú dì huáng 15 g, tù sī zĭ 15 g One dose is for one day. One half portion of the decoction was to be taken twice each day. After five doses, the signs and symptoms improved

significantly. At that time, xiān líng pí and shú fù zĭ were removed, and he was instructed to take seven more doses. After he finished the seven doses, all of the symptoms were gone.2 Comments: Over-work consumed the patient’s essence and qi, leading to spleen-kidney deficiency, and, finally, sinking of the center qi. When clear yang failed to ascend and nourish the mind, he suffered mental fatigue and somnolence. In the prescription, Bŭ Zhōng Yì Qì Tāng plus shú fù zĭ, xiān líng pí, and tù sī zĭ were used to supplement and warm kidney yang, boost the center, and raise clear yang. Má huáng helped to ascend yang qi with its rising nature. When accompanied by shēng má and chái hú, the three medicinals raise clear yang to nurture the house of the spirit. In addition, má huáng is proven to excite the cerebrum, midbrain, and medulla oblongata according to modern pharmacological research. 1 Liu Bao-yi. Comments on Liu’s Selected Case Records of Four Physicians 评校柳选四家医 案.Shanghai: Shanghai College of TCM Publishing House; 1993. p. 64-65. 2 Li Guo-jian. Modified Bŭ Zhōng Yì Qì Tāng for Difficult Cases 补中益⽓汤加减治疗疑难杂 症举隅. China’s Naturopathy. 2009; (17): 2.

Shēng Mài Săn ⽣脉散Pulse-Engendering Powder Source Text Origins of Medicine (Yī Xué Qĭ Yuán, 医学启源)

Formula Ingredients

Preparation and Administration It was noted in the source text that the formula should be decocted with running spring water and taken anytime. The modern method is to decoct and take one dosage three times within one day.

Formula Indications 1.Qi and yin consumption due to warm-heat or summerheat invasion. The clinical manifestations include profuse sweating, mental fatigue, general sluggish sensation, lack of strength, weak breathing, reluctance to speak, dry throat, and thirst. The tongue is red and dry with a scanty coating and the pulse is deficient and rapid. 2.Deficiency of both qi and yin due to a prolonged cough. The clinical manifestations include a dry cough with little expectoration, weak breathing, spontaneous sweating, and a dry mouth. The tongue is dry and the pulse is deficient and thready.

Analysis of Fundamental Pattern Pathogenesis Shēng Mài Săn is indicated for deficiency of both qi and yin. The deficiency pattern may follow a warm-heat or summer heat attack or caused by a chronic cough. When warm-heat or summer heat attacks the body, there will be a loss of fluids due to sweating which can easily lead to qi and fluid deficiency. The lung governs the skin and body hair. Summer-heat impairs the lung qi. The lung qi fails to control the pores and protect the exterior of the body. The result is fluid leakage that manifests as profuse sweating. Weak breathing and reluctance to speak are caused by lung qi impairment, as it governs the qi. Profuse sweating consumes body fluids, as a result, there is not enough fluid to nourish the throat; therefore; thirst and dry throat occur. Mental fatigue, lack of strength, and the tongue and pulse manifestations are all signs of qi and yin consumption. Long term cough will damage the lung and cause qi and yin deficiency with the same manifestations. The treatment principle is to boost qi, nourish yin, and promote fluid production.

Formula Actions Boosts qi and promotes fluid production, astringes yin and arrests sweating.

Formula Analysis

Unique Combination Features Shēng Mài Săn combines supplementing, moistening, and astringent medicinals together to supplement both qi and yin. After taking this formula, the qi and fluid consumption recovers and the vessels return to normal, that is why it is named ”Shēng Mài” (which literally means to engender the pulse).

Further Clarification 1. Rén shēn in Shēng Mài Săn Ginseng is the most important medicinal to supplement the original qi and rescue from desertion by boosting the qi. The quality and variety of ginseng plays an important role in the effect. For severe deficiency of original qi, it is best to use hóng shēn or bié zhí shēn (wild ginseng that grows in the Korean peninsula). For yin deficiency, it is best to use shēng shài shēn or bái shēn. For deficiency with fire it is best to replace ginseng with xī yáng shēn (American ginseng). For mild qi and yin deficiency it is best to replace it with dăng shēn. Furthermore, the dosage of ginseng should be high in acute and severe cases and low in mild cases. The proper use of ginseng according to pattern identification will bring definite clinical results.

2. Modern use of Shēng Mài Săn in practice It is widely used to treat cardiovascular disease and shock, for which it is proved to be effective. These diseases always manifest with mental fatigue, lack of strength, profuse sweating, reluctance to speak, shortness of breath and panting, a pale or lusterless complexion, palpitation, a deficient pulse, etc. which are symptoms of insufficient qi and yin according to traditional Chinese medicine. This formula can significantly supplement the original qi, astringe yin, and arrest sweating. Besides, the three ingredients in the formula all act upon the heart channel, supplement heart qi, and settle the spirit. It is proven, through experimental research, to effectively stimulate the heart, regulate blood pressure, and improve metabolism of the myocardium. Therefore, it is recommended to inject the formula in emergency situations such as shock, heart failure, and cardiac arrhythmia with insufficiency of the heart and lung. This is not contradictory to the original intended use of the formula. Though injection differs from the tradition decoction, studies show that there are no significant differences in efficacy. While the decoction is better for acute myocardial infarction and shock, considering all of the factors involved in an emergency rescue, injections are more widely accepted because of their convenience and rapid effect. Shēng Mài Săn can also be used to treat patterns of both qi and yin deficiency in any condition by adjusting the dosages accordingly.

Formula Applications 1. Essential pattern differentiation Shēng Mài Săn is a basic formula applicable to deficiency of both qi and yin. This clinical pattern is marked by:

2. Modifications

3. Modern applications Shēng Mài Săn is widely used for the following diseases that have the pattern of both qi and yin deficiency: pulmonary tuberculosis, chronic bronchitis, cough, vexation and insomnia caused by neurasthenia, cardiac arrhythmia, etc. Shēng Mài Injection is proven by pharmacological research to have little toxicity and wide margin of safety. It is often used to treat acute myocardial infarction, cardiac shock, toxic shock, hemorrhagic shock, coronary heart disease, and endocrinopathy in patterns differentiated as deficiency of both qi and yin. 4. Cautions and contraindications It is inappropriate for patterns accompanied with invasion of external pathogens or for summerheat attack without qi and yin deficiency. For qi and yin deficiency due to chronic cough pattern, it is only appropriate for pure deficiency without excess complications.

Case Studies 1. Fever

Ms. Zhang, a 48-year-old cadre, had a repeating fever for more than five years. She had been diagnosed with Sicca Syndrome. She took Chinese medicinal decoctions to nourish yin and clear heat without good effects. When she was seen by Dr. Gao, she still had a low fever with her body temperature around 37.8˚C and complained of a dry mouth and throat, vexing heat in the five centers (chest, palms and soles), dizziness, fatigue, shortness of breath, spontaneous sweating, decreased food intake, loose, unformed stools, and soreness of her joints. Lab examinations measured her ESR at 30mm/h. Her tongue was red and her pulse was rapid and thready. She was diagnosed with fever due to yin deficiency. The treatment principle was to boost qi, nourish yin, clear heat, and promote body fluids. She was prescribed a modified Shēng Mài Săn composed of tài zĭ shēn 10 g, mài dōng 10 g, bái zhú 10 g, fú líng 10 g, shí hú 10g, gé gēn 10 g, mù guā 10 g, chì sháo 10 g, bái sháo 10 g, zhì gān căo 5 g, shēng dì 15g, wŭ wèi zĭ 5 g, shān yào 15 g, biē jiă 12 g, and dān pí 12 g. After taking eighteen doses, her temperature returned to normal and the other symptoms were much relieved. On her second visit biē jiă and dān pí were removed and huáng qí 15 g was added. After taking the revised prescription for another one month, the ESR results measured normal and all the symptoms disappeared.1 Comments: sicca syndrome is mainly characterized by dryness-heat signs; however, nourishing yin and clearing heat does not help it. Dr. Gao applied the methods of boosting qi, promoting fluid production, nourishing yin, and clearing heat which proved beneficial for the patient. This is because dryness-heat will disappear by itself when its cause is resolved. 2. Palpitations Ms. Sun, a 35-year-old farmer presented with paroxysmal palpitations, chest oppression, and shortness of breath for two months without a distinct

cause. She also suffered from frequent insomnia, over-thinking, spontaneous sweating after slight/mild work, and lack of strength. Her menses were scanty with a light-red color and her cycle was irregular. Her tongue was red with cracks in the tip, and the coating was scanty. Her pulse was hasty. She was diagnosed with heart qi and yin deficiency and was prescribed dăng shēn 15 g, mài mén dōng 15 g, wŭ wèi zĭ 10 g, lóng gŭ 30 g, mŭ lì 30 g, yuăn zhì 10 g, suān zăo rén 15 g, băi zĭ rén 10 g, and dān shēn 15 g. She was instructed to prepare it as decoction and take one dose each day. Three doses later, she came for a second visit. The palpitations were significantly relieved. The chest oppression had disappeared. Sweating and sleeping also improved. Now that it was effective, she was instructed to take nine more doses. After which, all the symptoms disappeared and the ECG measured normal. Three more doses were taken to consolidate the effects, and the disease was finally cured.2 Comments: Premature cardiac beat pertains to “palpitation” in terms of traditional Chinese medicine. The disease mechanism is complicated and its common patterns include yang deficiency of the heart and kidney, deficiency of both qi and yin, blood deficiency of the heart and spleen, blood stasis obstructing the collaterals, liver qi constraint, and damp-phlegm obstruction. This case was caused by heart qi and yin deficiency that fails to nourish the heart. Therefore, the treatment principle was to supplement qi and yin, nourish the heart, and calm the mind and modified Shēng Mài Săn was prescribed. 3. Coronary heart disease 1 Wang Fa-wei, Yu You-shan, Xue Chang-lian. Medical Cases from Gao Hui-yuan ⾼辉远临证 验案精选. Beijing: Academy Press; 1995. p. 27. 2 Wang Hong-xiao. Four Cases of Treating Cardiac Premature Beat with Chinese Herbal Medicinals中药治疗早搏4则. Hebei Journal of Traditional Chinese Medicine. 2000; (22): 8.

Mr. Liu, 55 years old, came in for an initial visit on July 8th, 2002. He felt chest stuffiness over the past five days. It was severe at night when he was resting and accompanied by shortness of breath and sweating when he was doing physical work. He was instructed to use aminophylline and Fù Fāng Dān Shēn Piàn (Compound Danshen Tablets) by his community doctor which did not seem to help much, so he went to the community health center for further treatment. A physical examination revealed that his temperature was 36.8˚C, heart rate 78 bpm, and blood pressure 150/90 mmHg. ECG findings showed sinus rhythm and blood insufficiency of the coronary artery. His pattern was differentiated as heart qi deficiency. He was prescribed Shēng Mài Săn plus huáng qí 30g, bái zhú 18g, sū zĭ 15g, chuān xiōng 15g, chì sháo 12g, and gān căo 10g. He was instructed to take one dose each day for five consecutive days. At his follow-up visit, the patient reported an improvement of his condition. The chest stuffiness and shortness of breath were gone and the limbs were less weak. Sū zĭ was removed and dān shēn 20g was added to the former prescription. He was suggested to take ten more dosages of the formula. After that, the ECG returned normal. Within a one year follow-up, the patient had returned to normal without reoccurrence.1 Comments: This case was caused by impairment of both qi and yin with blood stasis and phlegm obstruction. In the prescription, Shēng Mài Săn was used to supplement heart qi and yin. Chuān xiōng and chì sháo were used to invigorate the blood and dissolve blood stasis. Sū zĭ was used to direct qi downward and dissolve phlegm. Huáng qí and bái zhú were used to boost qi and fortify the spleen, which is regarded as the source of qi and blood production. Altogether, this prescription works to supplement qi and promote fluid production (to treat the root) and invigorate the blood and

dissolve blood stasis (to treat the branch). It treats the root and branch simultaneously with more emphasis on the root problem.

Yù Píng Fēng Săn ⽟屏风散Jade Wind-Barrier Powder Source Text Categorized Collection of Medical Formulas (Yī Fāng Lèi Jù, 医⽅类 聚)

Formula Ingredients

Preparation and Administration Cut the ingredients into small pieces and take 3 qian (9 g) each time. Add one and a half zhan of water and a piece of dà zăo and decoct until 30% of the water vaporizes. Remove the dregs and take it when warm.

Formula Indications Yù Píng Fēng Săn is indicated for patterns of spontaneous sweating due to exterior deficiency. Sweating, aversion to wind, a pale complexion, a pale tongue with a thin and white coating, and a floating, deficient pulse mark the clinical manifestations. It is also used to treat patients with a deficient constitution and deficient wei qi that is vulnerable to external wind pathogens.

Analysis of Fundamental Pattern Pathogenesis

1 Zhang Meng-mei, Xiu Rong. 55 Cases of Coronary Heart Disease Treated with Shēng Mài Săn ⽣脉散治疗冠⼼病55例. Traditional Chinese Medicine and Materia Medica. 2007; 45: 19.

Yù Píng Fēng Săn is used to treat patterns of wei qi deficiency that fails to consolidate the exterior. Wei qi deficiency means that the striae and interstices are loose and not consolidated which leaves the body vulnerable, easy to be attacked by pathogenic wind. So an aversion to wind develops and it becomes easy to catch a cold. When wei qi fails to consolidate the exterior, ying-yin leaks out to cause frequent spontaneous sweating. A pale complexion, a pale tongue, and a floating, deficient pulse all reflect qi deficiency. Hence the treatment is to boost qi, reinforce zheng qi, consolidate the exterior, and arrest sweating.

Formula Actions Boosts qi, consolidates the exterior, and arrests sweating.

Formula Analysis

Unique Combination Features Yù Píng Fēng Săn is mainly composed of medicinals that supplement qi and consolidate the exterior used in combination with a medicinal, in a

smaller amount, that dispels the wind to release the exterior. With the help of fáng fēng, zhì huáng qí consolidates the exterior without keeping the pathogens lodged inside the body. Fáng fēng, in combination with huáng qí, expels the wind without harming the zheng qi.

Further Clarification 1. Compatibility of fáng fēng When wind attacks the body, it is easy to apply medicinals that expel the wind. However, for the patient with loose interstitial spaces due to wei qi deficiency, common medicinals of this type would induce sweating and worsen the exterior deficiency. Fáng fēng, as a sweet-warm natured medicinal, works mildly on the exterior to expel the wind. It is not dry and does not disturb the wei yang while it expels the wind. With its help, huáng qí works better to boost qi and consolidate the exterior. In the same way, fáng fēng expels the wind without harming the zheng qi because of huáng qí. 2. Why this formula is named “Yù Píng Fēng” (literally means Jade Wind-Barrier)? The difficulty in treating external contraction in patients with a deficient-constitution is the tendency of recurrence. It is easy to find a treatment method that combats external pathogens but it is difficult to find a treatment method that prevents external contraction. As the recurrence is caused by exterior deficiency, the formula must contain medicinals that boost the qi, consolidate the exterior, and expel the wind. This formula meets all three of these functions. Therefore, those with a deficient constitution, susceptible to external wind, should cherish this formula as they would jade. Yù Píng Fēng Săn acts like a wind barrier to prevent further external wind contraction. That is why it is named Yù Píng Fēng, “jade wind-barrier”.

Formula Applications 1. Essential pattern differentiation Yù Píng Fēng Săn is commonly used to treat spontaneous sweating due to exterior deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications Yù Píng Fēng Săn is currently used to treat patients with allergic rhinitis, upper respiratory tract infection, and glomerulonephritis when their condition is differentiated as a pattern of exterior deficiency. 4. Cautions and contraindications It is inappropriate for sweating due to external contraction or night sweat due to yin deficiency.

Comparison & Contrast Yù Píng Fēng Săn vs. Guì Zhī Tāng

Case Studies 1. Pediatric upper respiratory tract infection A 6-year-old boy suffered from a repeating upper respiratory tract infection for almost two years. He received many kinds of patent drugs to control the symptoms, including anti-infectious drugs, supplements, and immunopotentiators. However, these methods failed to prevent the disease from recurring. When he was brought to the doctor, the presenting signs and symptoms included mental fatigue, a pale complexion, profuse sweating, a light red tongue with scanty coating, and a deep, thready pulse. He was diagnosed as qi and yin deficiency of the lung and spleen. The prescription was huáng qí 12 g, bái zhú (dry-fried) 6 g, fáng fēng 6 g, tài zĭ shēn 10 g,

yún líng 8 g, wŭ wèi zĭ 8 g, băi hé 8 g, and jié gĕng 6 g. The formula was prepared as a decoction and one dose was taken each day. After taking the formula for two weeks, the frequency of recurrence decreased. Following three months of consecutive use, the disease was under control. His parents then prepared the formula as a medicinal extract and fed it to the boy for half a year. The boy reported no recurrence at a one-year follow-up.1 Comments: Children’s bodies and qi are not abundant, their zang-fu organs are delicate, and their striae and interstices are loose. They are therefore vulnerable to external pathogens. A history of upper respiratory tract infection weakens the skin and hair and leads to a disharmony between ying and wei qi. Simply stated, it impairs the lung and spleen qi, which increases susceptibility. Yù Píng Fēng Săn is used to boost qi and consolidate the exterior, reinforce zheng qi, and dispel pathogens. It works by enriching the exterior qi to protect the body from external contraction. Tài zĭ shēn and yún líng are used to strengthen the spleen. This helps to boost lung qi, or “foster the earth to generate metal” according to the five-phase theory. Wŭ wèi zĭ and băi hé astringe lung qi, enrich, and nourish lung yin to prevent wei qi from further consumption at the exterior. Jié gĕng is used to guide the medicinals up to act on the lung. 2. Cold-induced urticaria A 32-year-old female came to visit the doctor for the first time on December 7th, 2007. Her chief complaint was cold-induced (wind-cold or cold water exposure) wheals and unbearable pruritus all over the body for three years. They became aggravated during the winter and relieved during the summer. The wheals came back again this time when she caught a cold. She also complained of mental fatigue and lack of strength. She had been prescribed many different anti-histamine medications and some medicinals

without satisfactory results. The presenting signs included white wheals in different sizes with clear margins between each other. Her tongue was light red with a thin, white coating. Her condition was diagnosed as cold-induced urticaria due to external wind-cold contraction that caused disharmony between ying qi and wei qi. Her constitution was one of exterior qi and wei yang deficiency. The treatment principle was to boost qi and consolidate the exterior, harmonize ying and wei levels, dispel wind, and release the flesh. The prescription contained huáng qí 30 g, bái zhú 10 g, fáng fēng 10 g, guì zhī 10 g, bái sháo 10 g, chì sháo 10 g, dāng guī 10 g, shēng jiāng 10 g, gān căo 10 g, dà zăo 6 pieces, and dăng shēn 10 g. She was prescribed five doses to be taken as a decoction. On the second visit, the patient reported decreased wheals and pruritus after three doses. The wheals appeared only in a small amount in the morning following. So another five doses of the same formula were prescribed. On the third visit, the pruritus had stopped and no more wheals were visible. The patient was instructed to take five more doses to consolidate the effect and she reported no recurrence since then.2 1 Liu Yu-he. Modified Yù Píng Fēng Săn to Treat or Prevent Recurrent Pediatric Upper Respiratory Tract Infection: 56 Cases加味⽟屏风散防治⼩⼉反复上呼吸道感染56例. Traditional Chinese Medicine and Materia Medica. 2009; (6): 4. 2 Kang Jun. Treating Cold-Induced Urticaria with Yù Píng Fēng Săn and Guì Zhī Tāng: 87 Cases ⽟屏风散合桂枝汤治疗寒冷性荨麻疹87例. Guangming Journal of Chinese Medicine. 2009; (24): 4.

Comments: Cold-induced urticaria is termed yĭn zhĕn (瘾疹). It is differentiated as exterior wei deficiency and external wind-cold contraction pattern, according to the clinical manifestations. Yù Píng Fēng Săn was used to boost qi and consolidate the exterior. Guì Zhī Tāng was used to harmonize the ying and wei levels, dispel the wind, and release the flesh. Dāng guī and chì sháo were used to supplement and activate the blood. Dăng shēn was used to

supplement qi and fortify spleen. They work together to boost exterior qi, release the flesh, and dispel wind.

Wán Dài Tāng 完带汤Discharge-Ceasing Decoction Source Text Fu Qing-zhu’s [Treatise on] Gynecology (Fù Shì Nǚ Kē, 傅氏女科)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications Wán Dài Tāng is designed to treat disorders of vaginal discharge caused by liver constraint and spleen deficiency. This pattern is marked by thin, clear-white vaginal discharge (similar to clear nasal discharge), a pale

complexion, general sluggishness, and thin, unformed stool. The tongue is pale with a white coating and the pulse is moderate or soggy and weak.

Analysis of Fundamental Pattern Pathogenesis Wán Dài Tāng is a common formula used to treat abnormal vaginal discharge due to spleen deficiency and liver constraint. The dai mai fails to ensure retention and damp-turbidity then pours downward to become vaginal discharge. The pale complexion indicates spleen deficiency because a healthy complexion depends on abundant qi and blood transformed from the spleen and stomach. A deficient spleen qi fails to transform water and dampness and is unable to send the clear qi upward. Patients, thereby, always present with general sluggishness and thin, unformed stool. Spleen deficiency aggravated by liver constraint, complicated with dai mai insecurity, leads to turbid dampness flowing downward manifesting excessive clear vaginal discharge. The pale tongue and soggy, weak pulse both indicate spleen deficiency and excessive dampness. The therapeutic principles are to supplement spleen qi, soothe the liver and resolve constraint, resolve dampness, and arrest excessive vaginal discharge.

Formula Actions Fortifies the spleen and soothes the liver, removes dampness, and arrests vaginal discharge.

Formula Analysis

Unique Combination Features This formula contains a combination of supplementing and dispersing medicinals. It resolves turbid dampness by strengthening the spleen and rectifying the liver qi. All the medicinals work together to treat the abnormal discharge by boosting spleen qi, soothing the liver, and raising the clear yang.

Further Clarification The mechanism of liver constraint

There are no signs indicating liver constraint, so why it is included in the disease mechanism? The functions of the zang-fu organs are closely related with the normal ascending-descending movement of the body’s fluid and qi. Liver qi ascends them, lung qi descends them, spleen and stomach are the pivots, and the sanjiao provides the place for the movement. One can infer from the clinical manifestation that dampness pouring downward is due to spleen deficiency. The cause of the dampness is qi sunken in the lower jiao, which is due to liver qi constraint that fails to ascend properly. Therefore, the basic mechanism that leads to dampness pouring downward is spleen deficiency and liver constraint.

Formula Applications 1. Essential pattern differentiation Wán Dài Tāng is a common formula applicable to abnormal vaginal discharge due to spleen deficiency. This clinical pattern is marked by:

● thin, clear-white vaginal discharge ● pale tongue with white coating ● soggy, moderate pulse 2. Modifications

3. Modern applications Wán Dài Tāng is used to treat vaginitis, cervical erosion, and pelvic inflammation in patterns differentiated as spleen deficiency with liver constraint. 4. Cautions and contraindications It is inappropriate for yellow vaginal discharge caused by dampnessheat accumulation and long term liver constraint that has transformed into heat.

Case Studies 1. Edema Ms. Gao, 51 years old, came for an initial visit on March 4th, 1998. Three years ago, she had oligomenorrhea with a puffy face and extremities. The edema reduced with the treatment she received. However, she still had facial edema, edema of the lower extremities, abdominal distention following meals, poor appetite, thin, unformed stool, mental fatigue, and lack of strength. Her menses stopped in June 1998, following the treatment she underwent. She then went to many hospitals and was diagnosed with neurosis and menopausal syndrome after examinations. She had been treated with diuretics, medications that regulate vegetative nerve functions, and medicinal treatment to fortify the spleen, supplement the kidney, warm yang, and transform qi. While they could suppress the edema, they were not able to prevent its relapse. This time when she was brought to this doctor, she presented with a puffy, sallow yellow face and pitting edema on both lower extremities. Her tongue was dark and swollen with teeth-marks on the margin and the coating was thin and white. Her pulse was weak. It was diagnosed as liver constraint and spleen deficiency. Since the deficient earth

failed to control water, excessive dampness flooded the skin to cause edema. The treatment was to fortify the spleen, regulate qi, supplement the center, and remove dampness. Modified Wán Dài Tāng was prescribed containing dăng shēn 25 g, bái zhú 30 g, huáng qí 30 g, fú líng 15 g, cāng zhú 15 g, jīng jiè 10 g, chái hú 6 g, chē qián zĭ 10 g, chén pí 9 g, zĭ sū 10 g, dà fù pí 15 g, fáng jĭ 15 g, mù xiāng 6 g, sāng bái pí 15 g, and jiāng pí 6 g. The edema reduced after six doses. Following ten more doses, the edema and thin, unformed stools disappeared; and her mental spirit and appetite both improved. She was instructed to take water pills for another month made from the same formula without fáng jĭ and sāng bái pí. She reported no relapse at a six-month followup visit.1 Comments: It is said, “All dampness syndromes with swelling and fullness are ascribed to the spleen.” The three methods of treating edema introduced in The Yellow Emperor’s Inner Classic are to remove blood stasis, to induce sweating, and to promote urination. According to Teachings of [Zhu] Dan-xi, doctors should use rén shēn and bái zhú to supplement the spleen for water flooding patterns due to spleen deficiency. When the spleen is strengthened, water-dampness can be resolved on its own accord. It is, therefore, a must to treat dampness by supplementing the center qi. In this case, the patient was older than 49 years old, which means that the tiān guĭ has been exhausted and the spleen and kidney are deficient. When deficient earth fails to control the water, wood counter-restricts the earth. Water then floods the subcutaneous levels, resulting in edema. Long term edema impairs the qi movement and leads to liver constraint, which then over-restricts the spleen and worsens the edema. The pathological mechanism is liver constraint and spleen deficiency. The treatment principle is to fortify the spleen and rectify qi, and to supplement the center to remove dampness. In this prescription, Wán Dài Tāng is used to fortify the spleen, rectify qi, raise

yang, and eliminate dampness. Shēng huáng qí, fú líng, fáng jĭ, shēng jiāng, zĭ sū, dà fù pí and sāng bái pí are used to help supplement the spleen qi and promote urination in order to eliminate dampness. Mù xiāng and chén pí are used to soothe the liver qi and resolve constraint. This formula’s therapeutic effect comes from supplementing the spleen and soothing the liver qi. 2. Abnormal vaginal discharge Ms. Chen, 30 years old, came for an initial visit on Mar 13th, 1973. She was diagnosed with infertility and cervical erosion. She also presented with profuse vaginal discharge and swollen feet. The treatment principle was to fortify the spleen and drain dampness. The prescription was dăng shēn 12 g, zhì gān căo 6 g, huái shān yào 30 g, bái sháo 9 g, chē qián zĭ 9 g, chén pí 4.5 g, bái zhú 30 g, cāng zhú 9 g, jīng jiè 4.5 g, and Qiān Jīn Zhĭ Dài Wán (千⾦⽌带丸, Chinese patent medicine, ingredients: dăng shēn, bái zhú, bái sháo, dāng guī, chuān xiōng, xiāng fù, mù xiāng, shā rén, xiăo huí xiāng, yán hú suŏ, dù zhòng, xù duàn, bŭ gŭ zhī, jī guān huā, qīng dài, chūn pí, mŭ lì) 18 g (pills taken separately). After six doses, the patient reported reduced vaginal discharge and relieved discomfort in the waist and the legs. So she was suggested to take eight more doses.2 1 Zhang Ling-mei, Zhang Qing-lian, Wang Li-hua. Examples of Clinical Use of Wán Dài Tāng完 带汤临床应⽤举隅. Guangming Journal of Chinese Medicine. 2007; (22): 12. 2 He Ren. Medical Cases Treated by He Ren 何任医案. Hangzhou: Hangzhou Publishing House; 1978. p. 207.

Comments: Profuse vaginal discharge and swollen feet are signs of spleen qi deficiency. Since the ingested fluids and food cannot be transformed into essence, they travel downward into the uterus to become abnormal vaginal discharge. In this case, the doctor chose modified Wán Dài Tāng to boost spleen qi, resolve dampness, and raise yang. According to the records of the original text, a high dosage of bái zhú and shān yào is

emphasized. This is the reason for the high dose of the two medicinals in this prescription.

Section 2 Blood-Supplementing Formulas Blood-supplementing formulas are intended for patterns of blood deficiency manifesting a lusterless complexion, dizziness, palpitations, insomnia, pale lips and nails, a pale tongue, and a thready pulse. These formulas are mainly composed of medicinals that nourish the blood such as shú dì, dāng guī, bái sháo, and ē jiāo. Since qi is the commander of blood and is able to generate blood, medicinals such as rén shēn and huáng qí are always combined to boost qi and generate blood. Blood deficiency is easily complicated by blood stasis, therefore, medicinals that invigorate blood and dissolve blood stasis such as chuān xiōng and hóng huā are combined to dispel blood stasis and promote regeneration. For those who are manifesting deficient-heat resulting from insufficiency of yin-blood, dān pí and dì gŭ pí are added to clear away deficiency-heat. Medicinals that supplement blood have properties that are mostly yin .They are hard to be absorbed by the spleen-stomach, so they are always combined with medicinals that can awaken the spleen and regulate qi. Sì Wù Tāng, Guī Pí Tāng, and Dāng Guī Bŭ Xuè Tāng are the representative formulas.

Sì Wù Tāng 四物汤Four Substances Decoction Source Text Secret Prescriptions for Orthopedics and Traumatology from Immortals (Xiān Shòu Lĭ Shāng Xù Duàn Mì Fāng, 仙授理伤续断秘⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a course powder. For each dose, combine 15 g of the powder with about 1.5 zhan of water. Decoct until the total volume has reached 8 fen (160 ml). Take the decoction while it is warm, before meals. (Modern use: prepare and take as a decoction).

Formula Indications Sì Wù Tāng is used to treat patterns of ying-blood deficiency and stagnation manifesting dizziness, blurred vision, palpitations, insomnia, a lusterless complexion, menstrual irregularities, oligomenorrhea or amenorrhea, abdominal pain around the navel or mass(s) formed within the abdomen, a pale tongue, pale lips and nails, a thready, wiry pulse or thready, choppy pulse.

Analysis of Fundamental Pattern Pathogenesis Sì Wù Tāng is the chief formula used to supplement the blood and regulate menstruation. It is modified from Xiōng Guī Jiāo Ài Tāng recorded in Essentials from the Golden Cabinet, from which ē jiāo, ài yè and gān căo are removed. The pattern is caused by ying-blood deficiency with blood stagnation and deficiency of the chong mai and ren mai. Blood deficiency is closely related with the function of the heart and liver. The liver stores the blood; however, it cannot be fully nourished if there is blood deficiency. In a deficient condition, it is unable to send nutrients upward and dizziness will

then occur. The heart governs the blood and stores the spirit. In case of blood deficiency, the heart-spirit would be disturbed and manifest palpitations and insomnia. Yingblood depletion also results in malnutrition of the face, lips, tongue, and nails, so they appear pale and lusterless. The chong mai acts as the sea of blood and the ren mai is in charge of the uterus and pregnancy. Deficiency of the chong mai and ren mai, together with liver-blood insufficiency and blood stagnation, leads to menstrual irregularities such as scanty menstruation, pale menses, early or delayed menstruation, or even amenorrhea. The blood vessels are not fullyfilled and blood stasis forms easily. Therefore patients with this condition suffer from abdominal pain or hard mass formation. The thready, wiry and thready, choppy pulses indicate deficiency and stagnation of ying-blood. The treatment prioritizes supplementation and nourishment of the yingblood as the primary objective and harmonizing the blood vessels as the supportive, secondary objective.

Formula Actions Supplements and regulates the blood.

Formula Analysis

Unique Combination Features Medicinals that supplement the blood, shú dì and bái sháo, are used in combination with medicinals that move qi, dāng guī and chuān xiōng. Shú dì and bái sháo have a yin nature, while dāng guī and chuān xiōng have a yang nature. The combination allows for blood-supplementation without causing blood stagnation.

Formula Applications 1. Essential pattern differentiation According to Secret Prescriptions for Orthopedics and Traumatology from Immortals, Sì Wù Tāng is used to relieve pain from blood stasis caused by trauma. However, the Beneficial Formulas from the Taiping Imperial Pharmacy says that it is able to treat all kinds of women’s diseases. It serves as a basic formula to supplement blood and regulate menstruation. This clinical pattern is marked by:

2. Modifications

3. Modern applications Sì Wù Tāng is useful in the treatment of the following biomedical disorders and diseases which are caused by ying-blood stagnation due to blood deficiency: menstrual irregularities, pregnancy and postpartum issues, chronic skin problems like urticaria, allergic pupura, and neurogenic headaches. It also has some additional uses for diseases encountered in the orthopedics and traumatology department. 4. Cautions and contraindications It is inappropriate for the treatment of fever due to yin deficiency, profuse uterine bleeding, and qi desertion.

Associated Formulas Táo Hóng Sì Wù Tāng (Peach Kernel and Carthamus Four Substances Decoction, 桃红四物汤) [Source]

Usage of Medicinals Like That of Military Forces (Yī Lěi Yuán Róng,医 垒元戎) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Nourishes and invigorates blood. [Applicable Patterns] Blood deficiency and blood stasis. Symptoms include: early menstruation, copious amount of menses filled with clots, thick purple, sticky menses, and abdominal pain. Jiāo Ài Tāng (Donkey-Hide Gelatin and Mugwort Decoction, 胶艾汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Decoct the six medicinals with 5 sheng of water and 3 sheng of wine until 3 sheng left, remove the remainder and add ē jiāo to melt over a mild

flame. Take 1 sheng of warm decoction three times a day. [Actions] Nourishes blood, stanches bleeding, regulates menstruation, and calms the fetus. [Applicable Patterns] Deficiency of chong mai and ren mai, blood deficiency and cold exposure. Symptoms include: flooding and spotting, menorrhagia, constant vaginal dripping, postpartum persistent bleeding or after abortion, abdominal pain or vaginal bleeding during pregnancy. Shèng Yù Tāng ( Sage Healing Decoction 圣愈汤) [Source] Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Supplements qi and blood, and contains blood. [Applicable Patterns] Weakness of qi and blood where qi fails to contain blood. Symptoms include: early menstruation, menorrhagia, light colored menses, weak limbs,

mental and spiritual fatigue.

Dāng Guī Bŭ Xuè Tāng 当归补⾎汤Chinese Angelica Blood-Supplementing Decoction Source Text Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn, 内外伤辨惑论)

Formula Ingredients

Preparation and Administration Add 400 ml of water to the medicinals and boil until it has been reduced to 200 ml (Add 2 cups of water and boil until half is vaporized). Remove the residuals and take on an empty stomach while it is warm.

Formula Indications Dāng Guī Bŭ Xuè Tāng is used to treat fever caused by patterns of blood deficiency and floating yang. The symptoms are fever, a red complexion, vexing thirst, and a desire to drink. The pulses are surging, large, and deficient; however, forceless when one feels it with heavy pressure. It is also used to treat fever or headache that results from blood deficiency during pregnancy or after delivery or for ulcers that are slow or difficult to heal after breakout.

Analysis of Fundamental Pattern Pathogenesis

Dāng Guī Bŭ Xuè Tāng is used to treat qi and blood deficiency with yang qi floating to the exterior due to internal damage such as exhaustion and fatigue. Deficient qi and blood (yin) fail to maintain yang, so patients present with paroxysmal hot flashes, vexing thirst, and a desire for warm or hot drinks. The pulses are surging and deficient, yet forceless when pressed hard. These are the essential points for pattern identification. The fever is caused by blood deficiency that fails to contain yang. Since visible blood cannot be generated instantly, it consolidates the intangible qi as priority. The treatment therefore emphasizes the need to supplement qi and consolidate the exterior so the yang qi will once again take root. Once this happens and qi recovers, the fever will naturally disappear on its own.

Formula Actions Supplements qi and engenders blood.

Formula Analysis

Unique Combination Features Dāng Guī Bŭ Xuè Tāng is used to supplement qi and engender blood with an emphasis on supplementing qi. Huáng qí is used to supplement and consolidate the exterior qi together with dāng guī to enrich blood. Yingblood is engendered through the consolidation of the exterior wei qi.

Further Clarification The high dose of huáng qí Dāng Guī Bŭ Xuè Tāng is an important formula used for fever due to blood deficiency. Using dāng guī to supplement blood in this case is understandable. But why use such large amount of huáng qí to supplement qi? According to traditional Chinese medicine theory, qi and blood are physiologically interdependent. Qi is the commander of blood, because qi is needed to generate blood. Blood is the mother of qi, because blood is necessary to carry qi. When blood is deficient, the zang-fu organs, channels, and collaterals cannot get enough nutrition. In severe conditions, the blood is too deficient to carry qi, so the yang qi floats to the exterior, causing hot flashes and thirst. The severity of the fever reflects the extent of the yang floating due to blood deficiency. In the original text, it was recorded that the fever that Dāng Guī Bŭ Xuè Tāng can treat is as high as that treated by Bái Hŭ Tāng. From this statement, one can infer that there is an abundance of yang floating to the exterior. This is the reason for the high dose of huáng qí.

Formula Applications 1. Essential pattern differentiation Dāng Guī Bŭ Xuè Tāng is the basic formula to supplement qi and engender blood. It is also a representative formula that relieves fever with sweet-warm medicinals. This clinical pattern is marked by:

● hot flashes ● thirst ● desire for hot drinks ● large, deficient pulse, yet forceless when pressed hard

2. Modifications

3. Modern applications Dāng Guī Bŭ Xuè Tāng is used as a basic formula to treat anemia and allergic purpura in patterns differentiated, according to traditional Chinese medicine, as blood deficiency and qi weakness. 4. Cautions and contraindications It is prohibited in cases of tidal fever due to yin deficiency.

Comparison & Contrast It is stated in Clarifying Doubts about Damage from Internal and External Causes, “The only way to distinguish the applicable patterns between the two formulas is the pulse manifestation. For a fever without a big or excessive pulse, indicative of a Bái Hŭ Tāng condition, it would kill the patient if one used Bái Hŭ Tāng in this occasion.” [12] Dāng Guī Bŭ Xuè Tāng vs. Bái Hŭ Tāng

Continued

Case Studies 1. Chronic glossitis Mr. Zeng, a 34-year-old man, came to the clinic with the chief complaint of erosion of his tongue’s surface for over six months. The tongue was eroded but there was only a small amount of pain. The tongue appeared pale and swollen. The pulses felt to be thready and weak with deficient and floating quality on both cun. His eyes appeared dim. He also complained of mental fatigue and lack of strength. He was diagnosed with deficiency-fire flaming upward secondary to blood deficiency. The treatment was to boost qi and supplement blood so as to return the fire to its source. The prescription was a modified Dāng Guī Bŭ Xuè Tāng composed of huáng qí 50 g, dāng

guī 10 g, dăng shēn 15g, ròu guì 4 g, zhì gān căo 10 g, suān zăo rén 10 g, shí chāng pú 10 g, and shēng dì huáng 20 g. The erosion reduced significantly after five doses, with white and thin tongue moss growing in the margins. The tongue surface returned to normal after he finished another ten doses. He was instructed to take Guī Pí Wán for another two weeks to consolidate the effects. The patient reported no recurrences during the oneyear follow-up period.1 Comments: As the window of the heart, the tongue is actually nurtured by the foot taiyin spleen channel. When the spleen is deficient, it fails to provide enough nutrients to the tongue, and as a result, tongue erosion occurs. The previous doctors all attributed the erosion to heart fire and used many cold formulas to clear fire. But they damaged the spleen-stomach and aggravated ying-blood deficiency. Therefore, the erosion became stubborn, hard to heal. Doctor Zen Jing-song used Dāng Guī Bŭ Xuè Tāng as the chief to boost qi and supplement blood. Rén shēn, bái zhú, and zhì gān căo assisted Dāng Guī Bŭ Xuè Tāng to fortify spleen and reinforce qi. Ròu guì was added in a small amount in order to return fire to its source and to help with the growth of yin according to the yinyang interdependence theory. Shēng dì and suān zăo rén were used to restrain the warm-dry property of other medicinals, which may hinder fluid production. Chāng pú was used to guide the medicinals to work in the hand shaoyin heart channel. The medicinals and syndrome were consistent with each other, so the treatment was effective. 2. Fever due to blood deficiency 1 Zeng Jing-song. The Clinic Application of Dāng Guī Bŭ Xuè Tāng 当归补⾎汤的临床运⽤举 隅. Guiding Journal of TCM. 2007; (13): 4.

Dr. Zhang Lu-yu once treated a male who suffered from persistent hemoptysis due to overwork. The patient was given shēng dì juice and ink

without effects. He was then given two sheng of warm urine from children, which stopped the bleeding. After that, the patient had spontaneous sweating, panting, lack of strength and restlessness at night. Dr. Zhang was then called in. He determined that the pulse was big, wiry, and deficient. He prescribed four doses of Dāng Guī Bŭ Xuè Tāng, which stopped the fever.1 Comments: The symptoms of spontaneous sweating, panting, lack of strength, restlessness at night, and big, wiry, deficient pulse after sudden blood loss were obvious signs of yang qi floating to the exterior secondary to blood deficiency. Therefore, Dāng Guī Bŭ Xuè Tāng was prescribed in order to boost and consolidate the exterior qi and contain the floating yang, which relieved the deficiency-fever.

Guī Pí Tāng 归脾汤Spleen-Restoring Decoction Source Text Categorized Synopsis of the Whole (Zhèng Tĭ Lèi Yào, 正体类要)

Formula Ingredients

Preparation and Administration Add all of the medicinals of the formula, plus shēng jiāng and dà zăo, into water and decoct them.

Formula Indications 1.Qi and blood deficiency of the heart and spleen marked by palpitations, amnesia, insomnia, night sweat, deficiency-heat, tiredness,

reduced food intake, withered-sallow complexion, a pale tongue with a thin, white coating, and thready, weak pulses. 2.Spleen deficiency that fails to control the blood marked by hematochezia, subcutaneous purpura, flooding and spotting (bēng lòu, 崩漏), early menstruation, profuse pale menses, persistent vaginal bleeding, a pale tongue, and thready, weak pulses. 1 Yu Zhen. Comments on Ancient and Modern Case Records 古今医案按. Beijing: Huaxia Publishing House; 1997. p. 477.

Analysis of Fundamental Pattern Pathogenesis Guī Pí Tāng is used to treat qi and blood depletion due to overthinking or overwork. Overthinking damages the spleen. The spleen controls thinking and keeps the blood within the vessels. Therefore, patients manifest tiredness, anorexia, and deficiency-heat. Overwork injures the heart. The heart stores the spirit and governs blood and vessels. Therefore, patients present with blood insufficiency signs including palpitations, amnesia, insomnia, and night sweat. The other symptoms such as withered-sallow complexion, a pale tongue with a thin, white coating, and thready, slow pulses all indicate qi and blood insufficiency. Spleen deficiency and qi-blood deficiency is the basic pathology.

Formula Actions Boosts qi and supplements blood, fortifies the spleen and nourishes the heart.

Formula Analysis

Unique Combination Features First, this formula treats the heart and spleen at the same time. It emphasizes the spleen, which is the source of qi and blood production. This is the reason for the name “Guī Pí” (literal meaning “recover the normal function of spleen”). Second, this formula supplements qi and blood at the same time. It places more emphasis on qi, for qi is the commander of blood. Qi is able to produce blood and only when qi returns to normal can the heart be fully nourished by the blood produced by qi. Third, it contains a large group of supplementing medicinals, as well as one medicinal (mù xiāng) that regulates qi and awakens the spleen in order to avoid over-supplementing, which may cause qi and blood stagnation.

Formula Applications 1. Essential pattern differentiation Guī Pí Tāng is commonly used to treat qi and blood deficiency of the heart and spleen. This clinical pattern is marked by:

2. Modifications

3. Modern applications Guī Pí Tāng is often used to treat the following diseases with patterns identified as spleen-heart qi-blood deficiency or spleen failing to govern the blood: bleeding resulting from gastro-duodenal ulcer, dysfunctional uterine bleeding, aplastic anemia, thrombopenic purpura, neurasthenia, and cardiopathy.

Case Studies 1. Insomnia Ms. Liu, a 45-year-old lady, had her first visit to the doctor on October 9th, 2004. She had insomnia, excessive dreaming, spontaneous sweating, dizziness, palpitations, and poor appetite for the previous two months due to overwork. The current signs and symptoms are a dim and dark complexion,

mental fatigue, shortness of breath, reluctance to speak, a pale tongue with a thin, white coating, and thready, deep pulses. Her condition was diagnosed as insomnia due to heartspleen deficiency. The treatment was to boost the spleen qi, nourish blood, and calm the mind. The prescription was a modified Guī Pí Tāng containing rén shēn 12 g, bái zhú 15 g, huáng qí 20 g, fú shén 15 g, lóng yăn ròu 10 g, suān zăo rén 15 g, dāng guī 12 g, yuăn zhì 10 g, mù xiāng 10 g, zhì gān căo 12 g, wŭ wèi zĭ 10 g, shēng jiāng 3 pieces, and dà zăo 5 pieces. She was given five doses and instructed to take one dose per day, one half twice a day. On October 14th, 2004, she came for a second visit. This time, she reported mental improvement and that her insomnia was gone, but the palpitations and dizziness were still there. She was asked to take five more doses and after that, all the symptoms were gone.1 Comments: Overwork consumed her qi and blood and damaged her spleen and heart, as a result, there was not enough blood to nurture her heart so she developed palpitations and insomnia. In this prescription, Guī Pí Tāng was used to fortify the spleen, nourish the heart, and supplement qi and blood. Wŭ wèi zĭ was used to astringe the heart qi, calm the mind, and arrest sweating. 1 Wang Yan, Chang Xiu-sheng. Three Cases of Successful Clinical Application of Modified Guī Pí Tāng 归脾汤化裁验案3 则. Hebei Journal of Traditional Chinese Medicine. 2008; (30): 3.

2. Bloody stool (hematochezia) There was a patient who had repeated bloody stool. It was sometimes accompanied with abdominal pain or distention, decreased food intake, and a small, thready pulse. The doctor thought they were all signs of deficiency, so he prescribed Guī Pí Tāng plus jì cài huā, hé yè, and jīng mĭ.1

Comments: The symptoms such as bloody stool, a thready pulse, and decreased food intake are all due to deficient spleen qi, and it failing to control the blood. Therefore, the treatment is to supplement qi and contain blood. That is the reason the doctor chose to supplement with Guī Pí Tāng.

Section 3 Formulas that Supplement Both Qi and Blood Formulas in this section can be applied to dual qi and blood deficiency patterns marked by a pale complexion, dizziness, palpitation with or without precipitating factors, little food intake, fatigue, shortness of breath, unwillingness to speak, a pale tongue, and a deficient, thready, and forceless pulse. These formulas are often composed of qi-supplementing medicinals such as rén shēn, dăng shēn, bái zhú, and zhì gān căo and bloodsupplementing medicinals such as shú dì, dāng guī, bái sháo, and ē jiāo. The extent of the deficiency varies from case to case. There may be more blood deficiency or more qi deficiency in any given condition, so the primary and secondary roles of the qisupplementing and blood-supplementing medicinals will differ depending on the pattern. Medicinals that regulate and invigorate qi are also often combined in order so these formulas can supplement without causing stagnation. Representative formulas include Bā Zhèn Tāng and Zhì Gān Căo Tāng.

Bā Zhēn Tāng 八珍汤Eight-Gem Decoction a.k.a Bā Zhēn Săn (Eight-Gem Powder, 八珍散) Source Text Empirical Formulas from the Auspicious Bamboo Hall (Ruì Zhú Táng Jīng Yàn Fāng, 瑞⽵堂经验⽅)

Formula Ingredients

1 Liu Bao-yi. Comments on Liu’s Selected Case Records of Four Physicians 评校柳选四家医案. Shanghai: Publishing House of Shanghai College of Traditional Chinese Medicine;1993. p. 121.

Preparation and Administration Chop the medicinals into small pieces or cubes. Take nine grams of the formula; add five pieces of shēng jiāng and one piece of dà zăo, and boil together with three hundred milliliters water until thirty percent of the water is vaporized. Remove the dregs and drink the soup whenever necessary. It is also commonly prepared as a decoction with the same ingredients.

Formula Indications Bā Zhēn Tāng is intended for a syndrome of qi and blood deficiency marked by pale or witheredyellow complexion, dizziness, auditory vertigo, lassitude of the four limbs, shortness of breath, reluctance to speak, palpitations, and decreased food intake. The tongue is pale with a thin, white coating and the pulse is thready, weak or deficient, big, and weak.

Analysis of Fundamental Pattern Pathogenesis Patterns suitable for this formula are mostly those caused by delayed treatment in chronic illnesses, dysfunction following a disease, or massive blood loss. The disease is located in the heart, spleen, and liver. The

complexion, dizziness, auditory vertigo, palpitation, pale tongue with a thin, white coating, and a thready pulse all indicate heart and liver blood deficiency. The heart governs the blood while the liver stores the blood. The complexion, lack of strength in the four limbs, shortness of breath, reluctance to speak, poor appetite, and deficient forceless pulse indicate spleen qi deficiency as it governs transportation and transformation of food into qi and blood. Therefore, the treatment must supplement both qi and blood.

Formula Actions Boosts qi and supplements blood.

Formula Analysis

Unique Combination Features This formula is composed of Sì Jūn Zĭ Tāng and Sì Wù Tāng. Sì Jūn Zĭ Tāng is composed of rén shēn, bái zhú, fú líng, and zhì gān căo and is used to supplement the qi and reinforce the spleen. Sì Wù Tāng is composed of shú dì huáng, dāng guī, bái sháo, and chuān xiōng and is used to nourish blood and harmonize ying. Altogether, this formula works to supplement both qi and blood, and is named “Bā Zhēn Tāng”.

Formula Applications 1. Essential pattern differentiation Bā Zhēn Tāng is commonly used for patterns of qi and blood deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when they have been differentiated as patterns of qi and blood

deficiency: general weakness after a disease, various chronic diseases, menstrual irregularities, etc.

Associated Formulas Shí Quán Dà Bŭ Tāng (Perfect Major Supplementation Decoction, ⼗ 全⼤补汤) [Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Warms and nourishes qi and blood. [Applicable Patterns] Qi and blood deficiency. Symptoms include: a withered-yellow complexion, poor appetite, fatigue, dizziness, shortness of breath, palpitation, spontaneous perspiration, night sweat, cold extremities, a pale tongue, a thready and weak pulse, irregular menstruation, flooding and spotting, sores or wounds that are difficult to heal.

Rén Shēn Yăng Róng Tāng (Ginseng Supporting and Nourishing Decoction, ⼈参养荣汤) [Source] Treatise on Diseases, Patterns, and Formulas Related to the Unification of the Three Etiologies (Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn, 三因极⼀病证 ⽅论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Replenishes qi and nourishes blood, tranquilizes the mind by nourishing the heart. [Applicable Patterns] Qi and blood deficiency of the heart and spleen. Symptoms include: lassitude, poor appetite, easily to be sacred, amnesia, insomnia, spontaneous sweating, deficient fire signs such as dry pharynx and lips, dry skin, emaciation, cough and shortness of breath, severe panting after movement, sores or wounds that cannot completely heal due to qi and blood deficiency.

Tài Shān Pán Shí Săn (Taishan Mountain Massive Rock Powder, 泰 山磐⽯散) [Source] The Complete Compendium of Ancient and Modern Medical Works (Gŭ Jīn Yī Tŏng Dà Quán, 古今医统⼤全) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Nourishes qi and fortifies the spleen, and supplements blood to prevent abortion. [Applicable Patterns] Fetus insecurity due to qi and blood deficiency. Symptoms include: early miscarriage, habitual miscarriage, restless fetus with a pale complexion, lassitude, no appetite, a pale tongue with a thin, white coating, and a slippery, forceless pulse. All of the three formulas are modified from Bā Zhēn Tāng. Therefore, they all share the same function to reinforce qi and nourish blood. They are all effective for qi and blood deficiency patterns, yet they each have their unique properties:

● Bā Zhēn Tāng is relatively mild and aims to evenly reinforce qi and blood.

● Shí Quán Dà Bŭ Tāng is more warming because of the huáng qí and guì zhī that have been added.

● Rén Shēn Yăng Róng Tāng is made up of Shí Quán Dà Bŭ Tāng plus yuăn zhì, chén pí, and wŭ wèi zĭ. Chuān xiōng, a blood mover, is removed leaving this formula powerful to enrich blood and calm the mind.

● Tài Shān Pán Shí Săn is modified Shí Quán Dà Bŭ Tāng with guì zhī and fú líng removed and xù duàn added to reinforce the liver and kidney and supplement the chong mai and ren mai. Huáng qín, nuò mĭ, and shā rén are added to clear heat, nourish the stomach, and calm the fetus. With the modifications that have been listed, it becomes a formula specific for gynecology.

Case Studies 1. Constipation A 70-year-old male had his first visit on November 10th, 2006. His chief complaint was chronic constipation for ten years, which had been aggravated for one month. He had previously treated by many other doctors without satisfactory results. At the time of his visit, he was having difficulty to move his bowels even though he wanted to defecate. It always took him over thirty minutes to open the bowels. They were at first dry and then soft. He defecated once every two to five days. Accompanied symptoms included a lusterless complexion, mental and physical fatigue, weakness of breath, and poor appetite. His tongue was pale with a thin, white coating and his pulse was deficient. The patient had a history of chronic superficial gastritis. His condition was diagnosed as constipation due to qi and blood deficiency.

He was prescribed dāng guī 20 g, chuān xiōng 8 g, bái sháo 12 g, shú dì 18 g, hóng shēn 8 g, bái zhú 15 g, fú líng 12 g, zhì gān căo 8 g, huŏ má rén 12 g, shēng jiāng 3pieces, and dà zăo 2 pieces. After taking five doses, the patient reported an improvement of his symptoms. After five more doses, his defecation returned to normal. The patient was advised to take Bā Zhēn Kē Lì (granules) to consolidate the effects. He reported no relapse within a sixmonth follow-up.1 Comments: The most common type of senile constipation is caused by qi and blood deficiency. The qi and blood are consumed and become deficient as people age. The large intestine is lacking the energy needed to conduct and transmit contents from the stomach, and is lacking the fluid needed to moisten the path for yin-blood. As a result, constipation occurs. This formula is mainly composed of Bā Zhēn Tāng to replenish qi and nourish blood. There is an emphasis on the large amount of dāng guī and huŏ má rén needed to moisten the bowels and relieve constipation. Thereby, the constipation is cured when qi and blood become sufficient. 2. Restless fetus A pregnant women with a six-month-old fetus complained of weariness, poor appetite, a yellow complexion, afternoon tidal fever, delayed fetal development, and restless fetus. Dr. Xue Li-zhai saw her. He diagnosed her condition as deficiency of spleen qi. She was prescribed Bā Zhēn Tāng, with the amounts of rén shēn, bái zhú, and fú líng doubled. After she finished thirty doses, her appetite increased and the fetal development returned to normal. She also had no restlessness.2 Comments: This case is caused by spleen-stomach deficiency and qi and blood deficiency. The deficient blood fails to provide enough nutrition to the fetus, so the fetus becomes noticeably restless. Lassitude, poor appetite,

and a yellow complexion are signs of spleen deficiency. The deficient blood fails to control yang qi, so it floats to the surface manifesting as fever. Therefore, modified Bā Zhēn Tāng was used to supplement qi and blood effectively. 1 Li Li, Jiang Guang-xin. Examples of Successful Application of Bā Zhēn Tāng 八珍汤治验举 隅. National Medical Journal of China. 2008; (6): 9. 2 Jiang Guan, Wei Zhi-xiu. Classified Case Records of Famous Physicians (continued edition) 名 医类案（正续编）. Beijing: China Press of Traditional Chinese Medicine; 1996. p. 698.

Zhì Gān Căo Tāng 炙⽢草汤Honey-Fried Licorice Decoction a.k.a. Fù Mài Tāng (Pulse-Restoring Decoction, 复脉汤) Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Add all the medicinals except ē jiāo into 7 sheng of wine and 8 sheng of water. Decoct until 3 sheng remain. Remove the dregs, and then put ē jiāo in until it melts thoroughly. Take the decoction when it is warm, 1 sheng three times a day. (Modern preparation: prepare as a common decoction with ē jiāo infused.)

Formula Indications

1.Zhì Gān Căo Tāng is indicated for patterns of yin-blood and yang-qi deficiency with malnutrition of the heart vessel. The symptoms are intermittent or knotted pulse, palpitations, weakness, emaciation, weak breathing, etc. The tongue is peeled with a scanty or dry and thin coating. 2.Zhì Gān Căo Tāng is indicated for deficiency-consumption and lung atrophy. The symptoms are dry cough without expectoration, or spitting up a small amount of saliva, emaciation, shortness of breath, insomnia, vexation, spontaneous sweating or night sweat, a dry throat and tongue, dry stool, and a deficient, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis Zhì Gān Căo Tāng is a well-known formula from Treatise on Cold Damage used to treat an intermittent or knotted pulse and palpitations. This pattern is always seen in one of two circumstances. The first is the mistreatment of cold-induced diseases by sweating, vomiting, or purging; or from blood loss after catching a cold-induced disease. The second is a miscellaneous disease due to yin-blood insufficiency and deficiency of yang qi. The insufficient yin-blood fails to fill in the blood vessel and deficient yang qi fails to activate or pump the blood vessel, these two leading to an intermittent or knotted pulse. Yin-blood insufficiency fails to nourish the heart mind and heart yang deficiency fails to warm the heart vessels, so the patient complains of palpitations. The treatment should be to enrich heart yin, nourish heart blood, boost heart qi, and warm heart yang in order to restore the pulse and calm palpitations.

Formula Actions Boosts qi, enriches yin, unblocks yang, and restores the pulse.

Formula Analysis

Unique Combination Features Zhì Gān Căo Tāng is nourishing but not greasy, and warm but not dry. It supplements the deficiency and unblocks the channels simultaneously so as to make qi and blood abundant, yin and yang harmonious, and the channels and vessels unblocked.

Further Clarification About the chief medicinal This formula contains many medicinals that nourish yin and blood. Among them, the dosage of shēng dì huáng is the highest. Its quantity is many times more than that of gān căo. Yet, gān căo is the chief medicinal and not shēng dì huáng. Why is that? The effect of gān căo to supplement qi is much less significant than that of rén shēn. In addition, it cannot supplement the blood either. However, its dosage in this formula (4 liang) is the highest among all of Zhang Zhongjing’s formulas containing gān căo. From this, one may conclude that zhì gān căo, in this formula, is specifically used for its ability to treat an irregular pulse and palpitations rather than its more commonly used functions. According to Miscellaneous Records of Famous Physicians, gān căo has the effect of unblocking the channels and vessels, which, in common words, means that it can relieve spasms of the blood vessels. It is stated in Basic Questions that the five zang-organs are all nourished through the channels and collaterals that transport blood and qi. When the heart fails to pump blood normally, fail to transport blood to the the blood vessels in a normal manner. Some of the blood vessels may cramp thereby, the pulse becomes intermittent or knotted upon palpation. According to traditional Chinese medical theory, large amounts of gān căo and dà zăo, with their sweet property, can ease the spasms of vessels and aid the recovery of the heart’s function. It is regarded as the chief medicinal for this reason.

Formula Applications 1. Essential pattern differentiation

Zhì Gān Căo Tāng is a formula that supplements yin, yang, qi, and blood at the same time. This clinical pattern is marked by:

2. Modifications

3. Modern applications Zhì Gān Căo Tāng is commonly, and effectively, used for functional arrhythmia and extra systole. It can be used, with appropriate modifications, for disease conditions such as coronary disease, rheumatic heart disease, viral myocarditis, hyperthyroidism, etc. that present with palpitations, shortness of breath, and an intermittent or knotted pulse. These conditions must be identified as patterns of yinblood insufficiency and yang qi deficiency according to traditional Chinese medical differentiation. It is also

applicable for deficiency-consumption and dry cough resulting from both qi and yin consumption. 4. Cautions and contraindications When Zhì Gān Căo Tāng is used to treat deficiency-consumption and lung wĕi disease due to qiyin deficiency, one should decrease the dosage of, or omit, the warm medicinals such as shēng jiāng, guì zhī, and wine since they will cause more yin-fluids deficiency.

Associated Formulas Jiā Jiăn Fù Mài Tāng (Pulse-Restoring Variant Decoction, 加减复脉 汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Enriches yin and nourishes blood, engenders fluid, and moistens dryness. [Applicable Patterns]

Yin-fluids deficiency in the late stage of warm disease due to lingering pathogenic heat. Jiā Jiăn Fù Mài Tāng is a modification of Zhì Gān Căo Tāng (also known as fù mài tāng). It is used to treat yin deficiency caused by heat accumulation in the late stage of warm disease. By removing rén shēn, dà zăo, guì zhī, and shēng jiāng that warm yang and boost qi and adding bái sháo that nourishes blood and astringes yin, this formula’s main function is to enrich yin and nourish the fluids.

Comparison & Contrast Zhì Gān Căo Tāng vs. Shēng Mài Săn

Continued

Case Studies 1. Palpitations Mr. Wang suffered from palpitations and had a small, weak, and forceless pulse. He also complained of lassitude of his legs. He was prescribed Zhì Gān Căo Tāng composed of zhì gān căo 12 g, guì zhī 9 g, shēng jiāng 9 g, mài mén dōng 18 g, suān zăo rén 9 g, rén shēn 6 g, ē jiāo 6 g, shēng dì 48 g, and dà zăo 10 pieces. The prescription was prepared by adding all of the medicinals, except for ē jiāo, into four cups of water and three cups of wine. It was decocted until it reduced down to two cups. The dregs were then removed and ē jiāo was melted into the hot decoction. One dose was taken twice each day while warm. After four doses, his legs became stronger. After another additional four doses, the palpitations disappeared.1 Comments: The palpitations in this case did not occur with an irregular pulse. However, judging from his pulse and the concurrent lassitude of the legs, one could conclude that it is a deficient case with the same mechanisms of Zhì Gān Căo Tāng. Zhì Gān Căo Tāng was therefore applied with má rén replaced by suān zăo rén in order to strengthen the formula’s function to calm the heart and mind. 2. Night sweats Ms. Yang, 45 years old, came for her initial visit on October 27th, 2007. A month ago she overworked and began to sweat during her sleep. However, when she woke, the sweating gradually stopped. Her situation had recently aggravated, so she came to see the doctor. She had a sallow yellow complexion and complained of poor sleeping, fatigue, lack of strength, a dry mouth, poor memory, and dry stool. Her tongue was pale with teeth-marks

on the margins. Her pulse was deep and thready. She was diagnosed with night sweat due to qi-blood deficiency and disharmony of yin and yang. The treatment plan was to enrich yin, nourish blood, warm yang, and boost qi. She was prescribed a modified Zhì Gān Căo Tāng composed of zhì gān căo 18 g, dăng shēn 30 g, suān zăo rén 30 g, shān yú ròu 30 g, duàn mŭ lì 30 g, mài dōng 15 g, shēng dì 15 g, huŏ má rén 12 g, guì zhī 10 g, wŭ wèi zĭ 9 g, ē jiāo 9 g, shēng jiāng 5 pieces, and dà zăo 12 pieces. One dose was to be taken each day prepared as a decoction. After five doses, the night sweat and poor sleeping condition markedly improved and the stools normalized. After taking another fifteen doses, with the duàn mŭ lì removed, the night sweat stopped and the other symptoms disappeared.2 1 China Academy of TCM. Medical Cases of Yue Mei-zhong 岳美中医案集. Beijing: People’s Medical Publishing House; 1978. p. 65. 2 Song Jian-Zhong. Examples of Successful Clinical Application of Zhì Gān Căo Tāng 炙⽢草汤 治验举例. Zhejiang Journal of Traditional Chinese Medicine. 2009; (44): 1.

Comments: Over-thinking and overwork consumed her qi and blood. After a period of time, it caused qi, blood, yin, and yang deficiency. Yin failed to astringe yang so the yang floated to the exterior, carrying with it yin-fluids, so the patient developed night sweat. Zhì Gān Căo Tāng enriches yin and nourishes blood to strengthen the root, boosts qi, and warms yang to consolidate the exterior. Wŭ wèi zĭ, shān yú ròu, suān zăo rén, and duàn mŭ lì, were added to Zhì Gān Căo Tāng in order to enrich yin, supplement deficiency, calm the mind, and arrest sweating. It was designed to treat the root and the branch simultaneously. The night sweat had mostly stopped by the second visit, so the duàn mŭ lì was removed.

Section 4 Yin-Supplementing Formulas Yin-supplementing formulas are used to treat yin deficiency. Yin deficiency includes liverkidney yin deficiency, lung-stomach yin deficiency, and especially kidney yin deficiency. The signs and symptoms include marasmus, dizziness, tinnitus, tidal fever, hectic malar flush and warmth, vexing heat in the five centers (chest, palms, and soles), night sweat, insomnia, soreness of the waist, seminal emission, cough, expectoration of blood, a dry mouth and throat, a red tongue with less coating, and a thready rapid pulse. Common medicinals used to supplement yin are shēng dì, mài mén dōng, ē jiāo, bái sháo, băi hé, shí hú, and yù zhú. For liver-kidney yin deficiency accompanied by qi constraint, chuān liàn zĭ is added to soothe the liver qi. For yin deficiency accompanied with internal heat, zhī mŭ and huáng băi are added to clear deficient heat. Common formulas in this category are Liù Wèi Dì Huáng Wán, Dà Bŭ Yīn Wán, Yī Guàn Jiān, and Băi Hé Gù Jīn Tāng.

Liù Wèi Dì Huáng Wán 六味地黄丸Six-Ingredient Rehmannia Pill (Rehmannia Pill) a.k.a Dì Huáng Wán (Rehmannia Pill, 地黄丸) Source Text Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀)

Formula Ingredients

Preparation and Administration Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 3 pills are taken before meals with warm water. It can also be prepared as a decoction.

Formula Indications Liù Wèi Dì Huáng Wán is indicated for liver-kidney yin deficiency. The symptoms are soreness of the waist and knees, dizziness, tinnitus, deafness, night sweat, seminal emission, xiāo kĕ (wastingthirst, 消渴), steaming bone fever, feverish feeling in the palms and soles, a dry mouth and throat, loosening of the teeth, heel pain, dribbling of urine, and unclosed fontanel in children. The tongue is red with scanty coating and the pulse is deep, thready, and rapid.

Analysis of Fundamental Pattern Pathogenesis The kidney stores the essence and is considered to be the foundation of the congenital (prenatal) constitution. The liver stores the blood. Essence and blood can convert into each other. Therefore, yin and blood deficiency of the liver and kidney will usually interact with each other. The lumbus is the house of the kidney, which governs bone and generates marrow. The teeth

are the surplus of the bones and the knees are the house of the sinews. Therefore, kidney yin deficiency leads to an insufficiency of bone marrow, which causes soreness of the waist and knees and loosening of the teeth. The brain is the sea of marrow. Kidney yin deficiency fails to generate the marrow needed to replenish the brain. Deficient liver blood fails to supplement the brain and the eyes causing dizziness. The kidney opens its orifice into the ears. Deficient kidney yin is unable to supplement the upper part of the body. Also, deficient heat may affect the clear orifices and cause tinnitus and deafness. The kidney stores the essence. Kidney yin deficiency causes seminal emission due to ministerial fire disturbing the essence chamber. Yin deficiency generates internal heat, or may even cause deficiency fire to flame upward. The symptoms present as steaming bone fever, xiāo kĕ, night sweat, dribbling of urine, a red tongue with scanty coating, and a deep, thready, and rapid pulse. The failure of the fontanel to close in children is caused by slow bone growth due to kidney deficiency. The therapeutic principles used to remedy this pattern are to supplement liver-kidney yin, clear deficiency-heat, and drain damp-turbidity.

Formula Actions Supplements and nourishes the liver and kidney.

Formula Analysis

Continued

Unique Combination Features Liù Wèi Dì Huáng Wán is characterized by containing three supplementing medicinals and three draining medicinals. The formula emphasizes supplementation, so the dosage of the supplements is more than those that drain. This formula supplements yin of the kidney, liver, and spleen. However, kidney yin is the primary target of the supplementation.

Further Clarification 1.Why does the yin of the three organs need to be supplemented in the case of kidney yin deficiency? Liù Wèi Dì Huáng Wán is used to treat kidney yin deficiency. Medicinals in this formula, such as shú dì, shān zhū yú, and shān yào enter

the kidney, liver and spleen channels respectively. Therefore, it is said that this formula can supplement the yin of those three organs. The aim of using shān zhū yú in this formula is not to supplement the liver-spleen yin, but is rather used to supplement kidney yin according to the generation theory of the zang-fu organs. The liver and kidney supplement each other as the liver stores the blood and the kidney stores the essence. Blood and essence transform into each other. The spleen is the foundation of the postnatal constitution, responsible for qi and blood production. Supplementing the spleen helps preserve the prenatal essence and yin. Gong Ju-zhong once said that “Shān yào is a key medicinal to supplement the spleen; it can also supplement the kidney indirectly because once the spleen qi is strong, it is able to transform food into essence that can be delivered to the kidney and nourish it. In this way, the kidney essence and qi is enriched by boosting spleen”. In this formula, a large amount of shú dì is used to supplement the kidney yin directly. Shān zhū yú and shān yào are combined to supplement the kidney yin indirectly. This formula is also used to supplement the liver and spleen yin or for patients with kidney yin deficiency combined with liver yin or spleen yin deficiency. The clinical applications of this formula should primarily be for patterns differentiated as kidney yin deficiency. The socalled three yin supplementing refers to the supplementation of the kidney yin, liver yin, and spleen yin simultaneously. 2.Why are there three draining medicinals in a formula used to treat kidney yin deficiency? In zheng qi deficiency patterns, the treatment should be to supplement deficiency. Why are the three draining medicinals used in this formula? There are three reasons for their use. First, this formula is derived from Shèn Qì Wán recorded in Essentials from the Golden Cabinet. The doctor, Qian Yi, created the formula by removing guì zhī and fù zĭ, which supplement fire

and assist yang, from Shèn Qì Wán. Shèn Qì Wán is used to treat water metabolism disorders due to kidney yang deficiency. Zé xiè and fú líng are used in the formula to drain accumulated water-dampness and turbidity from the kidney. Since the kidney is responsible for water metabolism, waterdampness retains easily whether there is kidney yang or yin deficiency. Second, yin deficiency and disharmony between water and fire can often cause stirring-up of deficiency-fire. Therefore, mŭ dān pí is used to clear heat and drain fire. Third, all three medicinals are used to eliminate pathogens and balance the greasy nature of the three yin-supplementing medicinals. Therefore, it is important to keep these three draining medicinals in the formula. Although the supplementing effect is not as strong as a formula made up of pure supplements, this formula can be taken for long time without causing any discomfort.

Formula Applications 1. Essential pattern differentiation Liù Wèi Dì Huáng Wán is a commonly used formula applicable to liverkidney yin deficiency. It is inappropriate for patients suffering diarrhea due to spleen deficiency.This clinical pattern is marked by:

2. Modifications

3. Modern applications Liù Wèi Dì Huáng Wán may be used in the following biomedically defined disorders when the patient shows signs of kidney yin deficiency: chronic nephritis, hypertension, diabetes, pulmonary tuberculosis, nephrotuberculosis, hyperthyroidism, central retinitis, anovulatory dysfunctional uterine bleeding, and menopausal syndrome.

Associated Formulas Zhī Băi Dì Huáng Wán (Anemarrhena, Phellodendron and Rehmannia Pill, 知柏地黄丸) [Source] Investigations of Medical Formulas (Yī Fāng Kăo, 医⽅考) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 2 qian (6 g) are taken before meals with warm water.

[Actions] Enriches yin and subdues fire. [Applicable Patterns] Liver-kidney yin deficiency complicated by deficiency-fire flaming upward. Symptoms include: dizziness, tinnitus and deafness, toothache due to deficiency-fire, vexing heat in the five centers, soreness of waist and knees, blood strangury and odynuria, seminal emission, steaming bone fever and night sweat, hectic malar flush and warmth, a dry mouth and throat, a red tongue, and a thready, rapid pulse. Qĭ Jú Dì Huáng Wán (Lycium Berry, Chrysanthemum and Rehmannia Pill, 杞菊地黄丸) [Source] Complete Treatise on Measles (Má Zhěn Quán Shū, 麻疹全书) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 3 qian (9 g) are taken before meals with warm water. [Actions] Supplements the kidney and liver and improves vision. [Applicable Patterns]

Liver-kidney yin deficiency. Symptoms include: blurred vision, dry eyes, and epiphora induced by wind. Mài Wèi Dì Huáng Wán (Ophiopogon tuber, Chinese Magnoliavine fruit and Rehmannia Pill, 麦味地黄丸) [Source] Complete Records of Medical Work quoted from A Compilation of Benevolent Formulas (Yī Bù Quán Lù : Tĭ Rén Huì Biān, 医部全录:体仁汇 编) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 3 qian (9 g) are taken before meals with warm water. [Actions] Supplements the lung and kidney. [Applicable Patterns] Lung-kidney yin deficiency. Symptoms include: vexation, cough, hematemesis, tidal fever, and night sweat. Dū Qì Wán (Qi-Restraining Pill, 都⽓丸) [Source] Symptoms, Causes, Pulses, and Treatment (Zhèng Yīn Mài Zhì, 证因脉 治)

[Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 2 qian (6 g) are taken before meals with warm water. [Actions] Supplements the kidney to improve qi reception. [Applicable Patterns] Lung and kidney deficiency. Symptoms include: cough, panting, hiccups, spontaneous seminal emission, and lumbar pain. Zhī Băi Dì Huáng Wán, Qĭ Jú Dì Huáng Wán, Mài Wèi Dì Huáng Wán, and Dū Qì Wán are modification of Liù Wèi Dì Huáng Wán. They all have the ability to supplement kidney yin. Zhī Băi Dì Huáng Wán has the action to enrich yin and subdue fire and is suitable for deficiency-fire flaming upward causing steaming bone fever, tidal fever, seminal emission, and night sweat. Qĭ Jú Dì Huáng Wán has the effect to supplement the liver and improve vision. It is therefore suitable for blurred vision caused by liverkidney yin deficiency. Mài Wèi Dì Huáng Wán has the action to supplement the lung and kidney and is suitable for treating cough caused by lung-kidney deficiency. Dū Qì Wán has the action to supplement the kidney and improve the absorption of qi. It is suitable for panting caused by kidney deficiency.

Case Studies 1. Deficiency-consumption

A 63-year-old male patient came to the clinic on July 8th, 2005. His chief complaint was fatigue, weakness of the four limbs, soreness of the waist and knees, dizziness, blurred vision, tinnitus, deafness, a dry mouth and throat, feverish feeling in palms and soles, night sweat, and seminal emission. The tongue was light red with a thin, white coating. The pulse was thready and slippery. The patient was diagnosed with deficiencyconsumption. The treatment principle was to supplement the liver and the kidney. Liù Wèi Dì Huáng Wán was applied. The prescription was composed of shú dì 15 g, shān yào 12 g, shān zhū yú 10 g, zé xiè 10 g, mŭ dān pí 10 g, fú líng 10 g, and shēng gān căo 6 g. Every day one dose was decocted with water to yield 100 ml. One half of it was taken orally twice a day. The symptoms were partially alleviated after three doses and then more were eliminated following another three doses. However, the patient still had symptoms of tinnitus, deafness, and a dry mouth and throat. Liù Wèi Dì Huáng Wán pills were then prescribed for three weeks, after which the symptoms were eliminated.1 Comments: Kidney yin deficiency and essence and blood deficiency cause deficiency-fire to harass the upper body. The symptoms include fatigue, weakness of the four limbs, soreness of the waist and knees, dizziness, blurred vision, tinnitus, and deafness. The appropriate treatment principle is to supplement kidney yin. Modified Liù Wèi Dì Huáng Wán should be used. 2. Edema A 70-year-old male patient came to the clinic on July 13th, 2007. The patient received bypass surgery two years ago. Recently, the patient developed edema of lower limbs, palpitations, shortness of breath, and occasional panting. The volume of his urine was still normal. He was not

thirsty nor did he have poor quality sleep. The patient sighed a lot. The tongue was red with a thin, dry coating. The right-hand pulse was slippery and the left-hand pulse was wiry with a weak chĭ position. The pattern was differentiated as kidney yin deficiency, liver constraint, and disorder of the transportation of body fluid causing dampness and water retention. The treatment principle was to supplement the liver and kidney, soothe the liver, resolve constraint, dispel dampness, and move water. Modified Liù Wèi Dì Huáng Wán was applied. The prescription was composed of shú dì 12 g, shān zhū yú 12 g, háng bái sháo l0 g, huái shān yào l0 g, zé xiè 15 g, dān pí 9 g, fú líng 12 g, huái niú xī l0 g, fáng jĭ 9 g, chōng wèi zĭ 9 g, ròu guì 4 g, and chŭ shí zĭ l0 g. After ingesting 7 doses of the formula, the leg edema was obviously reduced and the symptoms of palpitations and shortness of breath and panting were alleviated. Seven doses of the same formula were then prescribed at the second consultation. At the third visit, the treatment principle was adjusted to boost qi, raise yang, fortify the spleen, and drain dampness. Shēng Xiàn Tāng was combined with Fáng Jĭ Huáng Qí Tāng and modified. The patient recovered after another two months of treatment.2 1 Sheng Ping. Examples of Clinical Application of Liù Wèi Dì Huáng Wán (Tāng) 六味地黄丸 (汤)临床应⽤举隅. Qinghai Medical Journal. 2008; 38: 2. 2 Xue Ke. Xie Ming’s Treatment Experience of Miscellaneous Diseases by Using Liù Wèi Dì Huáng Wán 运⽤六味地黄丸治疗杂病的经验. Beijing Journal of Traditional Chinese Medicine. 2008; 27: 5.

Comments: In ancient formulas, the treatment of edema is mostly done with medicinals that promote urination instead of those that supplement. However, most edema is caused by internal damage instead of external contraction. The treatment to warm the spleen and supplement the kidney follows this concept. The patient mentioned in this case is an aged man with a weakened constitution. Although his main complaint was edema, it was accompanied by palpitations, shortness of breath, panting, a red tongue with

a dry coating, and a weak left-hand pulse at chĭ position. The main cause of his condition was kidney yin deficiency; which lead to its inability to contain and transform fluids. Liver deficiency causes its qi flow to be unsmooth. Water retention invades the upper body and causes qi and blood stagnation. However, the treatment should not only use purgation. Following the concept of treating the root and branch simultaneously, the treatment should mainly supplement the liver and kidney while soothing the liver, promoting urination, and assisting yang. Liù Wèi Dì Huáng Wán is mainly used to supplement kidney yin. Medicinals that soften the liver, invigorate blood, and promote urination are combined in this formula. A small amount of ròu guì is added to improve qi reception, relieve panting, and move water. Chōng wèi zĭ and huái niú xī are used to supplement the kidney, invigorate blood, and promote urination. Chŭ shí zĭ is combined with bái sháo to supplement the liver and deficiency, and move water. The formula is used to treat the root and branch simultaneously. As the medicinal combinations found in these formulas are well suited to the case, the effect is quick.

Zuŏ Guī Wán 左归丸Left-Restoring Pill Source Text The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书)

Formula Ingredients

Preparation and Administration Dì huáng is steamed, made into paste and prepared into pills the size of a phoenix tree seed using honey. A little more than a hundred pills, which equals to about nine grams, are swallowed before meals with boiled water or slightly salted water. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original medicinal ratios.

Formula Indications

Zuŏ Guī Wán is used to treat patterns of true yin deficiency marked by dizziness, blurred vision, soreness of the waist and knees, seminal emission, efflux diarrhea, spontaneous sweating, night sweat, a dry mouth and tongue, a red tongue with a scanty coating, and a thready pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by deficiency of the true yin, essence, and marrow. The kidney stores the essence, is in charge of the bones, and generates marrow. Deficiency of kidney yin, essence, and marrow causes less essence to be stored causing symptoms such as dizziness, blurred vision, soreness of the waist and knees, seminal emission, and efflux diarrhea. Yin deficiency with yang hyperactivity, forcing body liquids to leak out, causes symptoms of spontaneous sweating and night sweat. Yin deficiency, which fails to moisten the upper part of the body, causes a dry mouth and tongue and a red tongue with little coating. The thready pulse is a sign of true yin deficiency. The treatment is to supplement the water and cultivate true yin.

Formula Actions Enriches kidney yin, supplements essence, and boosts marrow.

Formula Analysis

Unique Combination Features This formula purely supplements without any purging effects; it tries to supplement yin better by combining a little bit of yang-supplementing medicinals.

Further Clarification An explanation of the combination of yang-supplementing medicinals:

Since yin and yang are rooted in each other, pathological yin deficiency affects yang and yang deficiency also influences yin. Therefore, only supplementing yin in a yin deficiency pattern may make supporting yang difficult and slow down the recovery of yin. Yin-supplementing medicinals, in large amounts, also damage yang within the body. In order to strengthen the yin-supplementing effect, a small amount of yang-supplementing medicinals is added to the formula. It is said by Zhang Jie-bin in The Classified Classic (Lèi Jīng, 类经) that “one who is good at supplementing yin must seek yin within yang, then yin will be better generated and produced by yang”. [5]

Formula Applications 1. Essential pattern differentiation Zuŏ Guī Wán serves as the most common formula applied for true yin deficiency. The medicinals in this formula are mainly used to supplement yin. Therefore, long-term administration may cause stagnation of the spleen and stomach. This formula is to be used cautiously for patients suffering from diarrhea due to spleen deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency of kidney yin, essences, and marrow: senile dementia, menopausal syndrome, senile osteoporosis, amenorrhea, and oligohypomenorrhea.

Associated Formulas Zuŏ Guī Yĭn (Left-Restoring Beverage, 左归饮) [Source] The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书) [Ingredients]

[Preparation and Administration]

Prepare it as a decoction. [Actions] Supplements kidney yin. [Applicable Patterns] True yin deficiency. Symptoms marked by: soreness of the waist, seminal emission, night sweat, a dry mouth and throat, thirst with a desire to drink, a red tongue tip, and a thready, rapid pulse. Zuŏ Guī Yĭn and Zuŏ Guī Wán are both applicable for kidney yin deficiency. They both contain only supplementing medicinals. However, Zuŏ Guī Yĭn has less medicinals so the kidney yin-supplementing action is less than Zuŏ Guī Wán. Zuŏ Guī Yĭn is suitable for mild kidney yin deficiency patients.

Comparison & Contrast In the Six Medical Texts of Wang Xu-gao (Wáng Xù Gāo Yī Shū Lìu Zhŏng, 王旭⾼医书六种), Versified Compilation of Patterns and Treatment Based on Medical Formulas (Yī Fāng Zhèng Zhì Huì Biān Gē Jué, 医⽅证 治汇编歌诀), it is said that “Zuŏ Guī Wán cultivates yin to generate yang instead of enriching water to control fire.” [13] Zuŏ Guī Wán vs. Liù Wèi Dì Huáng Wán

Case Studies 1. Oligohypomenorrhea A 24-year-old female patient reported oligohypomenorrhea as a chief complaint when she came to the clinic on September 26th, 2003. She had her menarche at the age of 18. Her menstruation lasts for one to two days, every thirty days. The amount of menstruate was scanty, sometimes just a few drops. Her last menstruation cycle was September 12th to the 13th. She only had a small amount of pale-red menstruate with a watery quality. Her symptoms included dizziness, tinnitus, soreness of the lumbar regions, scanty leukorrhea, a pale tongue with a thin, white coating, and a deep, thready pulse. Her menarche was late with a small amount of bleeding. She had soreness of the lumbar regions and tinnitus. The syndrome was

differentiated as kidney qi deficiency with essence and blood deficiency. Modified Zuŏ Guī Wán was applied to supplement the kidney, enrich blood, and regulate menstruation. The prescription was composed of shú dì 12 g, shān yào 12 g, shān zhū yú 12 g, fú líng 12 g, dāng guī 10 g, chuān xiōng10 g, táo rén 10 g, hóng huā 10 g, jī xuè téng10 g, gŏu qĭ zĭ 15 g, tù sī zĭ 15 g, niú xī 15 g, lù jiăo jiāo 15 g, guī băn jiāo 15 g, xuán shēn 15 g, and nǚ zhēn zĭ 15 g. After ingesting the formula for fifteen days, the menstruation started with an increased amount. Five days after menstruation, the formula was added with chén pí 10 g and shā rén 10 g. This formula was taken for three menstrual cycles. The menstrual amount was normal. Then the patient continued to take the same formula for two months. The menstruation was normal in the follow-up half a year later.1 Comments: The patient had a late menarche that produces only a little menstruate. She has soreness of the lumbar regions, tinnitus, etc. that make it obvious that her condition is due to kidney qi, essence, and blood deficiency. Therefore, modified Zuŏ Guī Wán was applied to supplement the kidney, enrich blood, and regulate menstruation. Tù sī zĭ, niú xī and lù jiăo jiāo were used to supplement kidney qi. Shú dì, shān zhū yú, gŏu qĭ zĭ, guī jiāo, xuán shēn and nǚ zhēn zĭ were used to supplement kidney yin. Shān yào and fú líng were used to fortify the spleen and harmonize the center. Dāng guī was used to enrich blood. Chuān xiōng, táo rén, hóng huā, and jī xuè téng were used to invigorate blood, regulate menstruation, boost kidney qi, and supplement essence and blood in order to regulate the chong mai and ren mai. 2. Dementia A 68-year-old female patient came to the clinic on September 2nd, 2001. The patient has an introverted personality with dizziness, deviated

neck, poor memory, tinnitus, and a sleeping disorder. Her symptoms included a dull facial expression, slow response time, a red tongue, and a thready, rapid pulse. The pattern is kidney yin deficiency. Modified Zuŏ Guī Wán, as a decoction, was applied to supplement kidney yin, benefit the brain, and open the orifices. The prescription was composed of shú dì huáng 24 g, shān yào 12 g, gŏu qĭ zĭ 10 g, shān zhū yú 10 g, huái niú xī 10 g, tù sī zĭ 12 g, lù jiăo jiāo (melted in decoction) 8 g, guī băn jiāo (melted in decoction) 15 g, yì zhì rén 10 g, and shí chāng pú 10 g. One dose of the decoction was given twice a day. After ingesting the formula for two months, the symptoms were alleviated. Zuŏ Guī Wán was prescribed for another three months and all of the symptoms were eliminated.2 Comments: The head is the house of bright essence and the sea of marrow. Decreased brain marrow presents as dementia with symptoms of decreased memory, understanding, judgement, calculation, orientation, slow thinking, and a dull facial expression. The kidney is in charge of the bones and generates marrow. Zuŏ Guī Wán was applied to supplement essence and marrow in order to treat the insufficient sea of marrow. Yì zhì rén and shí chāng pú are used to restore consciousness and open the orifices.

Dà Bŭ Yīn Wán ⼤补阴丸Major YinSupplementing Pill a.k.a Dà Bŭ Wán (MajorSupplementing Pill, ⼤补丸) Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

1 Zhang Jun-man. Clinical Application of Zuŏ Guī Wán Modification in the Gynecology Diseases左归丸加减在妇科疾病中的应⽤. Journal of Sichuan Traditional Medicine. 2007; 25: 5. 2 Yang Shi-zhen, Jia Shi-fu. Examples of Clinical Applications of Zuŏ Guī Wán 左归丸临床应 ⽤举隅. Hebei Journal of Traditional Chinese Medicine. 2006; 28: 3.

Preparation and Administration Grind the medicinals and combine them with steamed pig spinal marrow. Shape the mixture into pills using honey. Take seventy pills (6-9 g) with salt water before meals. The current preparation method is to grind the four medicinals mentioned above into fine powder and add it to a certain amount of steamed pig spinal marrow Then form the mixture into paste and add honey to form pills that weigh 15 g. One pill is orally administered in the morning and one in the evening with slightly salt water. It can also be

prepared as a decoction by adjusting the medicinal quantities based on the original ratios.

Formula Indications Dà Bŭ Yīn Wán is used to treat patterns of yin deficiency with deficiency fire marked by steaming bone fever, night sweat, seminal emission, cough, hemoptysis, vexation, irascibility, pain and redness of the feet and knees, a red tongue with scanty coating, and a rapid, powerful pulse at the chĭ position.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by liver-kidney deficiency, true yin deficiency, and exuberance of ministerial fire. The kidney is the viscus of water and fire. When the true yin is deficient, the ministerial fire is excessive and generates deficiency-fire. The symptoms include steaming bone fever, night sweat, seminal emission, pain and redness of feet and knees. Deficiency-fire even scorches the lung in this pattern causing cough and hemoptysis. Deficiencyfire harasses the heart spirit and causes vexation and irascibility. The therapeutic method is to powerfully supplement true yin and help subdue fire.

Formula Actions Enriches yin and subdues fire.

Formula Analysis

Continued

Unique Combination Features Dà Bŭ Yīn Wán is composed of yin-nourishing, heat-clearing, and firedraining medicinals. Its primary focus of nourishing yin and banking up the foundation is emphasized more than subduing fire and clearing the source.

Further Clarification This formula uses both yin-supplementing medicinals and fire-draining medicinals to cultivate and clear the origin. Its main action of treatment is to supplement yin and the origin while it helps subdue fire. In the Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴), it is said that “Yin is often insufficient, while yang is often in excess. Therefore, yin should be always supplemented and make it match with yang. So water is able to control fire” [14]. There is a large amount of guī băn and shú dì used in this formula. The ratio of guī băn and shú dì to zhī mŭ and huáng băi is

3∶2. This indicates that the main action of the formula is to supplement yin and the origin and assist with fire drainage. It is difficult to clear deficiencyfire in patterns of yin deficiency with vigorous fire when supplementing yin only, and not draining fire. However, if one simultaneously supplements yin while subduing fire, this pattern can be treated.

Formula Applications 1. Essential pattern differentiation Dà Bŭ Yīn Wán is the most common formula used to enrich yin and subdue fire. This formula should not be used in cases of spleen-stomach weakness, poor appetite, loose stool, and excessive fire and heat patterns. This clinical pattern is marked by:

● steaming bone fever ● red tongue with scanty coating ● rapid, powerful pulse at the chĭ position 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of yin deficiency with deficiency-fire

flaming up: hyperthyroidism, nephrotuberculosis, osseous tuberculosis, and diabetes.

Associated Formulas Hŭ Qián Wán (Hidden Tiger Pill, 虎潜丸) [Source] Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills using honey. 1 pill (9 g) is taken with lightly salted water or warm water twice a day. It can also be prepared as a decoction. [Actions] Enriches yin, subdues fire, strengthenes the sinews and bones. [Applicable Patterns] Wĕi (atrophy and/or flaccidity, 痿) due to liver-kidney deficiency and yin deficiency with internal heat. Symptoms include: soreness of the waist and knees, weak sinews and bones, thin legs and feet, fatigue when walking, dizziness, tinnitus, seminal emission, enuresis, a red tongue with scanty coating, and a weak, thready pulse.

Dà Bŭ Yīn Wán and Hŭ Qián Wán both enrich yin and clear heat with zhī mŭ, huáng băi, guī băn, and shú dì huáng. Suŏ yáng and hŭ gŭ are added in Hŭ Qián Wán to supplement kidney yang and strengthen the sinews and bones. It is suitable for soreness of the waist and knees and fatigue when walking due to poor nourishment of the sinews and bones. Dà Bŭ Yīn Wán is suitable for patients suffering from tidal fever and night sweat due to yin deficiency caused by vigorous fire.

Comparison & Contrast It is said in the The Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) that “Dà Bŭ Yīn Wán supplements true yin quickly in order to control the ministerial fire more effectively than Liù Wèi Dì Huáng Wán” [15]. Dà Bŭ Yīn Wán vs. Liù Wèi Dì Huáng Wán

Continued

Case Studies 1. Seminal emission A 24-year-old male patient reported seminal emission every several days for the past three years. When he is tired, the condition becomes more severe and occurs two or three times per night. His had a wiry pulse and his cheeks were red. His pattern was diagnosed as kidney yin deficiency, frenetic stirring of ministerial fire, and disturbance of the essence. Modified Dà Bŭ Yīn Wán was prescribed. The prescription was composed of shēng dì 3 qian, shú dì 3 qian, zhī mŭ 3 qian, huáng băi 3 qian, qiàn shí 3 qian, lián zĭ 3 qian, jīn yīng gāo (extract of jīn yīng zǐ, melted with boiling water) 6 qian, guī băn 8 qian, and mài dōng 5 qian.1 Comments: Frenetic stirring of the ministerial fire due to by kidney yin deficiency caused this case of seminal emission. The wiry pulse and redness of the cheeks were due to yin deficiency and vigorous fire. Dà Bŭ Yīn Wán was applied to supplement yin and drain fire. Qiàn shí, lián zĭ, and jīn yīng gāo were used to strengthen the consolidation of essence and better astringe seminal emission. 2. Insomnia 1 Fujian Institute of TCM. Selection of Fujian TCM Medical Records (Second Series) 福建中医 医案医话选编（第⼆辑）. Fuzhou: Fujian People’s Publishing House; 1963. p. 162.

A 22-year-old male patient came to the clinic on January 12th, 2004. He reported suffering with insomnia for the past two years. However, the insomnia became more severe over the past week. He received many treatments with little effect. It was difficult for him to fall asleep and concentrate. He was restless and had many dreams while sleeping. He would wake up very early and couldn’t fall asleep again. He also had soreness of the waist and legs, a dry throat at night, hemilateral headache on the left side with throbbing pain, poor appetite, a dry mouth, fatigue, and spontaneous sweating. His bowel movements and urination were regular. His tongue was dark with a yellow greasy coating and he had a thready, slippery pulse. His pattern was diagnosed as kidney yin deficiency and failure of the heart and kidney to interact. Modified Dà Bŭ Yīn Wán was prescribed to supplement kidney yin and restore the interaction between the heart and the kidney. The prescription was composed of shú dì 30 g, guī băn (decocted first) 20 g, huáng băi (dry-fried) 6 g, zhī mŭ 12 g, shān yú ròu 20 g, gŏu qĭ zĭ 15 g, chuān xiōng 30 g, zăo rén (dry-fried) 60 g, băi zĭ rén 40 g, zhēn zhū mŭ 40 g, zĭ bèi chĭ 40 g, quán xiē 3 g, wú gōng 3 pieces, gān căo 15 g, yè jiāo téng 20 g, and zhū shā (melted) 0.5 g. After ingesting seven doses of this decoction, the symptoms of excessive dreaming at night and waking up too early were alleviated. The spontaneous sweating, headache, and restlessness all improved. The patient still had difficulty to fall asleep, but his dry mouth and the soreness of waist and legs were alleviated. His tongue was dark with a thin yellow coating and his pulse was thready and wiry. In the follow-up formula, quán xiē and wú gōng were removed, 10 g of xuán shēn was added, and the amount of guī băn was changed to 30 g. Seven doses were prescribed and the patient had better sleep without any headaches. A good effect was achieved as the treatment and the symptoms matched each other. The formula was then administered to the patient with the zhū shā removed. According to the one-year follow-up, the patient had good sleep and mood.1

Comments: Insomnia is caused by disharmony of the zang-fu organs due to emotional disorders, irregular eating, excessive strain and relaxation, chronic diseases, and a weak constitution. Disharmony of yin and yang and disorder of the qi and blood are the causes of the disease. The pattern was diagnosed as kidney water deficiency, which fails to supplement the heart and control the heart fire. The heart spirit was harassed which caused the insomnia. The treatment was to supplement yin, clear heat, and restore the interaction between the heart and the kidney. The formula was assisted by medicinals that supplement the heart and calm the mind. Dà Bŭ Yīn Wán was used in combination with shān yú ròu and gŏu qĭ zĭ to supplement kidney yin. Fried zăo rén, băi zĭ rén, and yè jiāo téng are used to supplement blood and calm the mind. Zĭ bèi chĭ, zhēn zhū mŭ, and zhū shā are used to tranquilize the heart and calm the mind. The heart governs the blood and vessels. Yin deficiency with heat causes blood circulation disorders such as headache and dark tongue. Quán xiē, wú gōng, and chuān xiōng are used to invigorate blood, unblock the collaterals, and relieve pain.

Yī Guàn Jiān ⼀贯煎Effective Integration Decoction Source Text Supplement to ‘Classified Case Records of Famous Physicians’ (Xù Míng Yī Lèi Àn, 续名医类案)

Formula Ingredients

Preparation and Administration Prepare the formula as a decoction.

Formula Indications Yī Guàn Jiān is appropriate for patterns of liver-kidney yin deficiency with liver qi constraint characterized by pain in the chest, abdomen, and hypochondriac regions, acid regurgitation, bitter taste, dry mouth and throat, a dry, red tongue, and a thready, weak or weak, wiry pulse. This formula is also applied for shàn qì (hernia, 疝⽓). 1 Chang Zheng, Zhao Kai-sheng, Zhang Bing-hou, et al. Treatment Experiences Using Dà Bŭ Yīn Wán 运⽤⼤补阴丸类⽅的经验. Clinical Experiences of Experienced Traditional Medicine Doctors.

2006; 25: 9.

Analysis of Fundamental Pattern Pathogenesis The liver stores the blood and governs the free flow of qi. It is yin in form but yang in function. Wood prefers to be unconstrained and hates to be depressed. Liver-kidney yin and blood deficiency fail to supplement the liver and cause liver constraint, which harms the stomach. The symptoms include pain of the chest, abdomen, and hypochondriac regions, acid swallowing, and bitter taste. Long-term liver-qi constraint causes shàn qì and masses. Yin deficiency fails to ascend and leads to symptoms of dry mouth and throat, and a dry, red tongue. Yin and blood deficiency leads to insufficient blood in the vessels and cause the pulse to be thready and weak or deficient and wiry. The treatment principle is to supplement yin and blood and to soften and soothe the liver.

Formula Actions Enriches yin and soothes the liver.

Formula Analysis

Unique Combination Features This formula is composed of many yin-blood supplementing medicinals and a small amount of chuān liàn zĭ to soothe the liver and regulate qi. It combines medicinals that supplement the liver with one that soothes the liver in a formula that emphasizes on supplementing the liver. The purpose is to supplement the liver without making the formula too greasy or too nourishing for the spleenstomach to digest.

Further Clarification About the meaning of Yī Guàn: Yī Guàn was first recorded in Analects of Confucius (Lún Yǔn-Lǐ Rén, 论语·⾥仁). It means to use one theory in order to put everything into a

system. Not every yin-supplementing medicinal in this formula enters the liver channel. They, however, all have an effect onto the liver, either directly or indirectly, by way of supplementing water to moisten wood, cultivating earth to control wood, or clearing metal to control wood.

Formula Applications 1. Essential pattern differentiation Yī Guàn Jiān serves as a common formula used for abdominal and hypochondriac pain due to yin deficiency and qi stagnation. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of yin deficiency and qi stagnation: chronic hepatitis, chronic gastritis, gastric ulcer, duodenal ulcer, intercostal neuralgia, and neurosis. 4. Cautions and contraindications This formula is focused on supplementation. It circulates the invisible qi. However, it is unable to eliminate the visible evils. The enriching and cloying medicinals in this formula are not suitable for application in cases of phlegm and fluid retention with a white, greasy coating and a deep, wiry pulse.

Comparison & Contrast Yī Guàn Jiān vs. Xiāo Yáo Săn

Continued

Case Studies 1. Hypochondriac pain A 30-year-old patient had hypochondriac pain and a hard dish-shaped mass on the left ribs. The pain and distension became severe after eating and the patient was unable to lie down on his side. He had received many treatments, but they did not work and he was thinning. Somebody suggested that only Dr. Wei could treat his disease. When the doctor took the pulse, it was rapid and wiry. He determined that the disease was due to the liver. When blood is sufficient, the liver is in its normal state. However, now that the patient was angry, the liver yin was damaged and influenced the liver. As a classic book stated that liver disease affects the stomach. Distension of the left lobe of the liver makes the patient unable to lie down on their side. The distention of the right lobe of the liver influences the stomach and causes poor appetite. Other doctors, not knowing this, treated it inappropriately. The prescription was composed of shēng dì, shú dì, shā shēn, mài dōng, guā lóu

rén, yīng sù qiào, gŏu qĭ zĭ, and chuān liàn zĭ. After ingesting ten doses of the formula, all the symptoms were alleviated.1 Comments: Constrained liver qi transfers into heat, harming yin and blood. Liver constraint and yin deficiency causes hypochondriac pain with the inability to lie down on the side. Liver qi invading the stomach causes poor appetite. The treatment should supplement yin and soothe the liver with modified Yī Guàn Jiān. 2. Epigastric pain 1 Jiang Guan, Wei Zhi-xiu.Classified Case Records of Famous Physicians名医类案（正续编） . Beijing: China Press of Traditional Chinese Medicine; 1996. p. 804-805.

A 40-year-old teacher had recurrent epigastric pain for more than half a year. The diagnosis was chronic atrophic gastritis by gastroscope. The symptoms included dull stomach pain, distention after eating, and hypochondriac distention and pain that radiated to the back. Other symptoms included a dry mouth and throat, hiccups, soreness of the waist and knees, frequent yellow urine, dry stool, a red tongue with little coating, and a thready, wiry, and rapid pulse. The patient preferred to eat spicy food and thought too much. The patient took spicy medicinals to soothe the liver and regulate qi with little effect. The pattern was diagnosed as stagnant qi transfering into heat, which harmed the liver and spleen and caused yin deficiency of the stomach, liver, and kidney. Ye Tian-shi said, “Stomach is yang earth. Cold softens and drains the stomach.” Modified Yī Guàn Jiān was, therefore, prescribed to supplement qi and blood, invigorate blood, harmonize the center, and relieve pain. The prescription was composed of dāng guī 15 g, shā shēn 15 g, gŏu qĭ zĭ 15 g, yuán hú 15 g, yù jīn 15 g, wū yào 15 g, guā lóu rén 15 g, mài dōng 20 g, băi hé 20 g, bái sháo 30 g, shēng dì 30 g, chuān liàn zĭ 10 g, mài yá 30 g, dān shēn 30 g, and jié gĕng 20 g. After ingesting five doses of the decoction, all the symptoms were alleviated

and the urine and stool were normal. Five more doses were given. All in all, more than twenty doses were prescribed, no reoccurences were reported at a one-year follow-up.1 Comments: This patient preferred to eat spicy food and thought too much. The heat, which harms stomach yin, became stagnant and transferred into fire. The preference of spicy food further harms the stomach yin. The treating principle was to supplement yin, harmonize the stomach, regulate qi, and clear heat. The disease was located in the stomach and influenced the liver and the spleen. Therefore, Yī Guàn Jiān plus băi hé was applied to supplement liver-stomach yin and clear heat. Chuān liàn zĭ, yán hú suŏ, dān shēn, yù jīn, and wū yào were used to soothe the liver, regulate qi, invigorate blood, and dissolve stasis. Mài yá was used to promote digestion and harmonize the stomach. Jié gĕng was used to soothe the diaphragm and unbind the chest.

Section 5 Yang-Supplementing Formulas Yang-supplementing formulas are designed to address yang deficiency patterns. Yang deficiency usually involves the heart, spleen, and kidney. Formulas to treat yang deficiency of the heart and spleen have been covered in the interior-warming chapters, therefore; this chapter mainly focuses on those that treat kidney yang deficiency. Symptoms include a pale facial complexion, cold body and limbs, pain in the waist and knees, lack of strength in the lower limbs, dysuria or frequent urination, dribbling of urine, cramp and pain in the lower abdomen, impotence, premature ejaculation, and female infertility due to cold in the uterus, etc. The tongue is pale with a white coating. The pulse is deep and thin, especially at the chǐ position. Yang-supplementing formulas are often composed of yang-tonifying medicinals such as fù zĭ, ròu guì, bā jĭ tiān, ròu cōng róng, xiān líng pí, lù jiăo jiāo, and xiān máo as well as those that promote urination and tonify yin. It is recorded in The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū 景岳全书), “One who is good at tonifying yang will seek yang within yin, so that infinite generation and transformation of yang will be obtained with the help of yin.” [5] This is the reason for the compatibility with yin-supplements such as shú dì, shān zhū yú, and shān yào, which support the generation of yang and neutralize the warm-dryness of yangsupplements with their moistening nature. Water or dampness accumulates easily when kidney-yang becomes deficient and fails to warm qi and move water. This is why medicinals that help promote urination, such as fú líng

and zé xiè, are included. The representative formulas are Shèn Qì Wán and Yòu Guī Wán. 1 Gao Gui-sen, Ge Jun, Lu Jing. Clinical Treatment by Using Yī Guàn Jiān ⼀贯煎临证治疗体 会. China Journal of Current Traditional Chinese Medicine. 2006; 2: 8.

Shèn Qì Wán 肾⽓丸Kidney Qi Pill Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine powder. Then use honey to form the powder into pills the size of a phoenix tree seed. 15 pills (about 6 g) are taken for each dose, twice a day.

Formula Indications

Shèn Qì Wán is indicated for patterns of kidney yang deficiency manifesting lumbar pain, flaccidity of the lower limbs, cold sensation of the body below the waist, spasm of the lesser abdomen, dysuria or abnormally severe profuse urination at night, impotence, premature ejaculation, a pale, swollen tongue, and a deficient, weak pulse that is deep and thin at the chǐ position. It is also applicable for patterns of phlegm-retention, edema, xiāo kĕ, beriberi, bladder colic, and dysuria during pregnancy, and so on.

Analysis of Fundamental Pattern Pathogenesis Shèn Qì Wán is applicable for patterns of kidney-yang and mìng mén fire deficiency. The waist is the residence of kidney. The kidney is the foundation of the congenital constitution. It stores the true fire of mìng mén, which is the root of the body’s yang qi. The deficiency of mìng mén fire leads to an occurrence of various diseases. Deficient kidney yang fails to warm the lower jiao. Therefore, problems such as lumbar pain, flaccidity of the lower limbs, cold sensation below the waist, and cramping pain in the lesser abdomen develop. Deficient kidney yang is incapable of transforming qi and promoting urination, and as a result, water stays inside, causing dysuria, cramping pain in the lesser abdomen, or even bladder colic and dysuria while pregnant. Kidney yang should steam water-liquid, which rises to moisten the upper jiao. However, when it fails to do so the water-liquid descends directly into the lower jiao and fails to moisten the upper part. Therefore, problems such as increased urination and xiāo kĕ are noticed. The kidney governs water. Therefore, in the case of kidney yang deficiency, water retention symptoms occur including edema, phlegm-rheum, and beriberi. Although the symptoms vary from each other, the disease mechanism behind them is the same. This is, the so called, “different diseases, same treatment.” [16] The treatment is to supplement the fire and

assist yang. This treatment method is also known as “supplement the foundation of fire to remove the yin disease” [17] , as stated by Wang Bing.

Formula Actions Supplements the kidney and assists yang.

Formula Analysis

Unique Combination Features First, the yin-supplementing medicinals improve the ability of this formula to boost yang according to the yin-yang theory, this is the method of “seeking yang within yin”. Second, the combination of a small amount of yang-supplementing medicinals with a large amount of yinsupplementing

medicinals generates a mild fire to produce vital qi. Third, Shèn Qì Wán supplements and purges. It promotes diuresis and invigorates the blood simultaneously.

Further Clarification 1. On the combination of yin-supplementing medicinals It is easy to understand the use of yang-supplements in the case of yang deficiency. But what is the reason for using yin-supplements in this formula? The reason is the yin-yang relationship. Yin and yang are interdependent, rooted in each other physiologically. A deficiency of one will affect the other, pathologically. Yang-supplementing medicinals generate yang better when combined with yinsupplementing medicinals because yinsupplementing medicinals provide material. Yang depends upon yin because yang is based on yin. The formula warms and tonifies without impairing the fluids because the yin-supplementing medicinals counters the warm-dry properties of yang-supplementing medicinals. This is an illustration of what Zhang Jie-bin said, “One who is good at tonifying yang is able to seek yang within yin. From this, the generation and transformation of yang will be infinite.”(The Classified Classic, Lèi Jīng, 类经) 2. About the dosage of guì zhī and fù zĭ Zhang Shan-lei said, “The eight medicinals used to supplement kidney qi deficiency fail to generate true yang and lead to dysuria. In regards to the composition of the formula, none of the medicinals are related to diuresis. The formula is named ‘kidney qi’ mainly because of the emphasis on qi. So, the dosage of guì zhī and fù zĭ is small. They gently warm and lightly boost the kidney’s true yang and promote urination.” The formulas are used to address the symptoms of kidney yang deficiency and the retention of water

and dampness. Guì zhī and fù zĭ are intended to lightly boost the kidney’s true yang without generating too much fire that would damage the qi. Therefore, the dosage of guì zhī and fù zĭ is light so the fire is able to support the vital qi. 3. About gān dì huáng in the formula When xiān dì huáng is dried in the sun or over fire to eighty percent, pinch it into a block-shaped mass. It is then named “gān dì huáng”or “shēng dì huáng”. In later eras people mostly used shú dì huáng instead of gān dì huáng when prescribing formulas in order to increase nourishment. In the Song Dynasty, Yan Yong-he modified formulas by using shú dì huáng instead of gān dì huáng and referred to them as “Modified Shèn Qì Wán”, ”Shí Bŭ Wán”, and so on. However, Shèn Qì Wán is originally used for water-dampness retention, the usage of nourishing and greasy shú dì huáng may increase moisture. When compared to shú dì huáng, gān dì huáng has a colder property. However, it is less sticky and greasy than shú dì huáng. These two medicinals have their own different advantages and disadvantages. If we recognize that shú dì huáng, when used in place of gān dì huáng, will supplement the kidney in these formulas, it is relatively straight-forward.

Formula Applications 1. Essential pattern differentiation Shèn Qì Wán is commonly used to supplement the kidney and assist yang. This clinical pattern is marked by:

● lumbar pain and weak legs ● dysuria or abnormally increased urine

● pale, enlarged tongue ● deficient, weak pulse that is deep-thready at the chǐ position 2. Modifications

3. Modern applications Shèn Qì Wán is used as a basic formula to treat the following biomedical diseases, identified as kidney yang deficiency: chronic nephritis, diabetes, aldosteronism, hypothyroidism, neurasthenic, adrenocortical hypofunction, chronic bronchial asthma, climacteric syndrome, etc. 4. Cautions and contraindications The formula is inappropriate for patterns of kidney yin deficiency with deficiency-fire flaming upward manifesting a dry throat and mouth, and a red tongue with scanty coating. Moreover, it is inappropriate for a simple pattern of kidney yang deficiency without excess in which the urination is normal. Wu Yi-luo once said, “It (Shèn Qì Wán) is used for (kidney) deficiency complicated by excess accumulation, not for patterns of pure deficiency more suitable for Yòu Guī Wán or Yòu Guī Yĭn. If applied to pure deficiency patterns, the medicinals that drain the dampness and promote urination will reduce the formulas effect of supplementation.” [18] (Effective Use of Established Formulas, Chéng Fāng Qiè Yòng, 成⽅切⽤)

Associated Formulas

Ø Jiā Wèi Shèn Qì Wán (Supplemented Kidney Qi Pill, 加味肾⽓丸) [Source] Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 70 pills (9 g) are taken with rice water before meal. It can also be prepared as a decoction. [Actions] Warms the kidney and transforms qi, and promotes urination to relieve edema. [Applicable Patterns] Edema due to kidney yang deficiency. Symptoms include: lumbar heaviness, edema of the feet and dysuria. Ø Shí Bŭ Wán (Ten Supplements Pill, ⼗补丸) [Source] Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills the size of a phoenix tree seed using honey. 70 pills (9 g) are taken with salted water before meal. [Actions] Supplements kidney yang, and boosts essence and blood. [Applicable Patterns] Patterns of kidney yang and essence-blood insufficiency. Symptoms include: a dark complexion, cold and puffy feet, tinnitus, deafness, weak and thin body, weak knees and feet, dysuria, and lumbar pain. Jiā Wèi Shèn Qì Wán and Shí Bŭ Wán are both modifications of Shèn Qì Wán that warm and supplement kidney yang. Niú xī and chē qián zĭ are added to promote urination and relieve edema in addition to warming the kidney. Therefore, Jiā Wèi Shèn Qì Wán is designed to treat edema and dysuria resulting from kidney yang deficiency. Lù róng and wŭ wèi zĭ are added to Shí Bŭ Wán in order to increase the supplementation of kidney yang as well as to enrich the essence and blood. Therefore, it treats patterns of kidney yang insufficiency with essence and blood depletion.

Case Studies 1. Deficiency-panting

A patient suffering with panting came to the clinic. His symptoms included nasal obstruction, dry lips and mouth, cold knees, legs and feet, and so on. His pulse was deficient and small. His condition was diagnosed as kidney qi deficiency with abnormal qi rising upward. It was important that this case was not misdiagnosed as phlegm obstruction and treated with clearing methods. The doctor prescribed three qian of Shèn Qì Wán to be taken together with salted water.1 Comments: The kidney grasps the qi. The cold lower extremities and deficient, small pulse indicate kidney yang deficiency. Thereby, one could infer that the panting came from kidney yang deficiency. Shèn Qì Wán was therefore prescribed to supplement and assist kidney yang. 2. Chronic tonsillitis Ms. Cai, a 38-year-old lady, came to the doctor for the first time on July 2008. Her chief complaint was repeated enlargement of her tonsils with dull pain. Many other doctors had treated her with unsatisfactory results. She had been asked to have them surgically removed but she refused. When she was brought to this doctor, her tonsils on both sides were as large as almonds. They both appeared smooth and pale, indicating no blood congestion, and they felt soft. They have been enlarged for a long time without any signs of reduction even after many treatments. Her enlarged tonsils prevented her from normal swallowing at times. In addition, she complained of cold sensations of the lower extremities that began at the knees, sore loins, and frequent night urination. Her tongue was pale with slightly purplish edges and a moist, white coating. Her pulses were deep, thready, and delayed. She had no interest in tobacco or wine. Her appetite was normal. She was diagnosed with chronic tonsillitis due to kidney yang deficiency and coldphlegm obstruction. The treatment principle was to warm and supplement

kidney yang, dissolve phlegm, soften hardness, and dissipate masses. She was prescribed modified Shèn Qì Wán containing shú fù zĭ (decocted first) 9 g, shān zhū yú 9 g, shú dì huáng 15 g, fú líng 12 g, shān yào 12 g, dān pí 6 g, zé xiè 6 g, bái jiè zĭ 6 g, jié gĕng 6 g, jiāng cán (dry-fried) 10 g, shēng mŭ lì (decocted first) 30 g, guì zhī 5 g, and gān căo 5 g. She was instructed to take one half of the full dose of the decoction twice every day, after meals. After seven doses, the dull pain stopped and her swallowing returned to normal. The enlarged tonsils were then examined and found to be half of their former size. Her frequent night urination also improved. The tongue was light red with a white coating. Shú fù zĭ was reduced to 6 g and 3 g shān cí gū was added based on the former prescription. Seven more doses were taken and all the symptoms were gone after that. She was advised to take Jīn Guì Shèn Qì Wán for one month to consolidate the effect. She reported no relapse of the symptoms from the follow-up period until the time this case was published.2 1 Liu Bao-yi. Commentaries on Liu’s Selected Case Records of Four Physicians评校柳选四家医 案. Shanghai: Publishing House of Shanghai College of Traditional Chinese Medicine; 1993. p. 19. 2 Yu Xiao. Application of Shèn Qì Wán: Two Cases 肾⽓丸临证验案2则. Forum on Traditional Chinese Medicine. 2009; (24):1.

Comments: In ancient times, chronic tonsillitis was referred to as “rŭ é” (nippled moth, 乳蛾). In this case, the disease developed from either delayed treatment or mistreatment. The foot shaoyin kidney channel travels along the throat and reaches the bottom of the tongue. Enlarged tonsils, cold lower extremities, sore loins, frequent night urination, a pale tongue with purplish edges, a moist and white tongue coating, and a deep, thready, delayed pulse indicated kidney yang deficiency. Therefore, Shèn Qì Wán was used to warm and supplement kidney yang accompanied with bái jiè zĭ, jiāng cán, shēng mŭ lì, and Gān Jié Tāng to dissolve phlegm, soften hardness, and dissipate masses. Collectively, they treat the branch and the root at the same time.

Yòu Guī Wán 右归丸Right-Restoring Pill Source Text The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书)

Formula Ingredients

Preparation and Administration First steam shú dì huáng until it becomes mushy. Then grind up all the medicinals with a pestle and add honey. Finally, form them into pills the size of a phoenix tree seed. Take 100 pills at one time with boiled water or slightly salted water. Otherwise, the pill can be made larger into the size of a marble. Chew 2 or 3 of these pills and take with boiled water as a single dose. (Modern use: decoct the formula with the medicinals dosed according to the original proportions.)

Formula Indications Yòu Guī Wán is intended for patterns of kidney yang insufficiency and mìng mén fire deficiency marked by mental fatigue and general weakness due to aging or chronic disease, fear of cold, hypothermic limbs, sore loins, impotence, spermatorrhea, infertility, decreased food intake, unformed stools, urinary incontinence, a pale tongue with a white coating, and a deep, delayed pulse.

Analysis of Fundamental Pattern Pathogenesis The pattern treated with this formula is deficiency of both kidney yang and mìng mén fire. As the kidney is the viscus of water and fire, it stores mìng mén fire and is therefore regarded as the root of the original yang. Kidney yang deficiency and the decline of the mìng mén fire fail to warm the earth (spleen) affecting the spleen-stomach function. Thereby, the patient presents with mental fatigue, general weakness, sore and cold loins, decreased appetite, and unformed stools. The kidney dominates tiān guĭ (reproduction-stimulating essence, corresponds with the tenth heavenly stem, 天癸) and stores the essence. Therefore, kidney yang deficiency results in the decline of tiān guĭ and reproductive dysfunction manifesting impotence, spermatorrhea, infertility, and urinary incontinence. The treatment principle, as recorded in The Complete Works of [Zhang] Jing-yue, is to boost the source of the fire, namely, the original yang stored in the right kidney.

Formula Actions Warms and supplements kidney yang, supplements essence, and boosts marrow.

Formula Analysis

Unique Combination Features First, Yòu Guī Wán primarily warms and supplements kidney yang. It nourishes kidney yin and the essence as well. This is accomplished by the yin-yang relationship, “with the help of yin, infinite generation and transformation of yang can be attainable”, which is also known as “to seek yang within yin”. Second, this formula focuses on warming and supplementing, so it is suitable for patterns of pure deficiency.

Formula Applications

1. Essential pattern differentiation Yòu Guī Wán is often used to treat kidney yang deficiency and decline of mìng mén fire. This clinical pattern is marked by:

2. Modifications

3. Modern applications Modified Yòu Guī Wán can be used to treat the following diseases identified as patterns of kidney yang deficiency: nephrotic syndrome, senile osteoporosis, infertility, oligospermatism, anemia, and leucopenia. 4. Cautions and contraindications Yòu Guī Wán is intended for patterns of pure deficiency only. Therefore, it is inappropriate to prescribe for those with kidney deficiency

complicated with dampness accumulation, for it does not include medicinals that drain.

Associated Formula Yòu Guī Yĭn (Right-Restoring Beverage, 右归饮) [Source] The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书) [Ingredients]

[Actions] Warms and supplements kidney yang, and supplements essence and blood. [Applicable Patterns] Kidney yang deficiency. Symptoms include: timidity, mental fatigue, pain, sore back, cold extremities, impotence, seminal emission, thin, unformed stool, or exuberant yin repelling yang, true cold with false heat. Yòu Guī Yĭn and Yòu Guī Wán both treat patterns of kidney yang deficiency by warming kidney and supplementing essence. However, Yòu Guī Wán is stronger than Yòu Guī Yĭn in terms of warming the kidney yang and enriching essence and blood because it contains additional medicinals such as lù jiăo jiāo, tù sī zĭ, and dāng guī without gān căo.

Comparison & Contrast Yòu Guī Wán vs. Shèn Qì Wán

Case Studies 1. Diarrhea A 45-year-old man suffered from severe repeated cold-induced diarrhea for over ten years. It was accompanied with lumbar pain, cold feelings of the lumbus and extremities, and frequent, slow urination during the winter. He also reported feeling afraid, distracted, decreased sexual desire, easy to perspire, insomnia, etc. His pulse was slow and his tongue appeared swollen with the back of the coating greasy. Though the symptoms were diverse,

they all come from kidney yang and mìng mén fire deficiency failing to warm and generate the earth (spleen). During the times when he had no diarrhea, the treatment was to supplement and warm the kidney with Yòu Guī Wán to treat the root problem. While he suffered the diarrhea, he took Sì Shén Wán and Yòu Guī Wán at the same time.1 1 Qin Bo-wei. Qian Zhai Medicine Lecture Notes 谦斋医学讲稿. Shanghai: Shanghai Scientific and Technical Publishers; 2009. p. 152.

Comments: The diarrhea, in this case, was caused by kidney and mìng mén fire deficiency failing to warm and generate the earth (spleen). The concurrent symptoms of cold feelings in the waist and extremities, frequent urination, and decreased sexual desire, as well as, the pulse and tongue manifestations are all signs of kidney yang deficiency. Consequently, Yòu Guī Wán was chosen to warm and supplement kidney yang. 2. Senile pruritus A 65-year-old man suffered from repeated pruritus all over his skin for over three years. He had taken antihistamine medicines such as cetirizine, loratadine, and steroids to control the symptoms, which were somewhat helpful; however, the symptoms worsened after he stopped taking the drugs. When he was seen, he complained of itching and dry skin all over his body. The skin was covered with wide, scratched lesions, bloody scars, and lichenlike areas. His tongue was dark-red with a thin coating and his pulses were thready. He was prescribed modified Yòu Guī Wán composed of shú dì 18 g, shān zhū yú 12 g, tù sī zĭ 12 g, lù jiăo jiāo 8 g, dù zhòng10 g, gŏu qĭ zĭ 12 g, dāng guī 10 g, chuān xiōng 10 g, huáng qí 15 g, bái jí lí 12 g, dì fū zĭ 12 g, chán yī 10 g, and fáng fēng 8 g. He was instructed to take one dose each day, each dose being decocted twice and divided into two halves that were taken twice a day. He reported alleviation of the pruritus after one week and was instructed to take seven more doses. Afterwards, the itching was nearly gone

and the lesions greatly receded. Ten more doses with a slight modification of the formula were prescribed which cured the entire problem. He reported no recurrence within a six-month follow-up period.1 Comments: According to traditional Chinese medicine, senile pruritus pertains to wind disorders such as yăng fēng (痒风) and fēng sāo yăng (wind pruritus, 风瘙痒). Kidney yin deficiency and essence-blood insufficiency occurs naturally as people age. Pruritus may be regarded as a manifestation of interior wind due to blood deficiency. In this case, the dark color of the tongue indicated blood stasis and the thready pulse indicated kidney yin deficiency and blood insufficiency. Therefore, the treatment principle should be to supplement the liver and kidney, boost qi and nourish blood, invigorate blood, and expel wind. In the formula, shú dì, gŏu qĭ zĭ, shān zhū yú, tù sī zĭ, dù zhòng, and lù jiăo jiāo were all used to tonify the liver and kidney, warm kidney yang, and nourish essence and blood. Huáng qí was used to supplement qi and consolidate the exterior. Shú dì, gŏu qĭ zĭ, and dāng guī were used to supplement blood. Chuān xiōng and dāng guī were used to promote blood circulation and dispel stasis, which is helpful to dispel wind. Bái jí lí, dì fū zĭ, chán yī, and fáng fēng were used to dispel wind and stop pruritus. The whole formula was used to tonify the liver and kidney, supplement qi, reinforce the spleen, nourish and invigorate blood, protect the exterior, dispel wind, and relieve itching.

Section 6 Yin- and Yang-Supplementing Formulas 1 Liu Guo-an. Effects of Modified Yòu Guī Wán for Senile Pruritus: 120 Cases 右归丸加减治疗 ⽼年⽪肤瘙痒症120例疗效分析. Modern Medicine and Health. 2008; (24): 12.

Formulas that supplement both yin and yang may be applied to patterns of both yin and yang deficiency. The signs and symptoms are dizziness, soreness and weakness of the waist and knees, impotence and spermatorrhea, intolerance to cold and cold limbs, and afternoon tidal heat. Formulas in this chapter usually consist of yin-supplementing medicinals such as shú dì huáng, shān zhū yú, guī băn, hé shŏu wū, and gŏu qĭ zĭ and yangsupplementing medicinals such as ròu cōng róng, bā jĭ tiān, fù zĭ, ròu guì, and lù jiăo jiāo. Formulas contain them in differing dosage ratios depending on the priorities of yin deficiency or yang deficiency. Representative formulas include Dì Huáng Yĭn Zĭ and Guī Lù Èr Xiān Jiāo.

Dì Huáng Yĭn Zĭ 地黄饮⼦Rehmannia Drink a.k.a Dì Huáng Yĭn (地黄饮) Source Text Comprehensive Recording of Divine Assistance (Shèng Jì Zŏng Lù, 圣 济总录)

Formula Ingredients

Preparation and Administration Cut the medicinals down into a coarse powder and take 9-15 g as a draft. Add 1 zhan of water, 3 pieces of shēng jiāng and 2 pieces of dà zăo; boil them together until 30% of the water is vaporized. Remove the dregs and take the decoction before meals.

Formula Indications Dì Huáng Yĭn Zĭ is indicated for yīn fēi syndrome (aphasia and apraxia, 喑痱) due to kidney qi deficiency and phlegm invading upward manifested as aphasia due to stiffness of the tongue, apraxia of the legs, thirst without a desire to drink, cold legs, and flushed face. The pulse is deep, thin, and weak.

Analysis of Fundamental Pattern Pathogenesis

Yīn fēi is a disease name from ancient times. Yīn refers to aphasia due to stiff tongue and fēi refers to apraxia of the legs. They are caused by the obstruction of phlegm in the orifices due to yin and yang deficiency of the kidney. The kidney stores the essence and governs the bones. Yin and yang deficiencies of the kidney fail to provide enough nutrition to the sinew and bones and therefore manifests with weakness or even flaccidity of the sinews and bones. The foot shaoyin kidney channel travels up to the tongue. When the tongue is lacking nutrition due to kidney deficiency and is aggravated by phlegm obstruction, stiff tongue and aphasia occurs. Kidney deficiency and internal heat causes one to be thirsty without having the desire to drink. When the deficient yang floats to the exterior, the face becomes flushed. If the deficient kidney yang cannot provide enough warmth, the legs become cold. The deep, thready, and rapid pulse indicates both yin and yang deficiency. These symptoms are more prevalent in the elderly and in those following a serious illness. The treatment is to supplement the original (kidney) qi and strengthen yang as the primary method, and to open the orifices, resolve phlegm and soothe the heart qi as the assisting method.

Formula Actions Nourishes kidney yin, supplements kidney yang, opens the orifices, and resolves phlegm.

Formula Analysis

Unique Combination Features Dì Huáng Yĭn Zĭ supplements yin and yang equally as the number and quantity of the yinsupplements and yang-supplement are nearly the same. It

treats the upper and lower body simultaneously with more emphasis on supplementing the lower body.

Further Clarification About the mechanism yīn fēi: The root mechanism for yīn fēi syndrome is deficiency of both kidney yin and kidney yang. Kidney qi fails to transform water when the kidney yang is deficient. Therefore, water is retained and forms into damp-phlegm. Kidney yin fails to contain yang and interior deficient-heat manifests. The foot shaoyin kidney channel travels along the root of the tongue, so the vessels of tongue will be obstructed once the deficient fire and phlegm ascend. As a result, the yīn fēi syndrome occurs.

Formula Applications 1. Essential pattern differentiation Dì Huáng Yĭn Zĭ is a common formula used to treat yīn fēi caused by kidney deficiency. This clinical pattern is marked by:

● aphasia with a stiff tongue ● apraxia of the legs ● deep, thready, and weak pulse 2. Modifications

3. Modern applications Dì Huáng Yĭn Zĭ can be used with modifications to treat the following biomedical diseases when differentiated as yin and yang deficiency: terminal hypertension, cerebral arteriosclerosis, sequela of apoplexy, myelitis, etc. 4. Cautions and contraindications This formula is characterized by its equal strength in supplementing yin and yang, and mild property that warms without causing dryness. However, it is not appropriate for those with hyperactivity of liver yang or flaming of qi and fire combined with apparent heat signs.

Case Studies 1. Yīn fēi (aphasia and apraxia, 喑痱) Xu, a 68-year-old male, was admitted to the hospital for right side hemiplegia and blurred speech with an apathetic facial expression. His tongue appeared pale and dark with a thin, white, and greasy coating. His pulse was deep and thready. He had a Western medicine diagnosis of cerebral infarction, encephalatrophy, and high-risk hypertension. His traditional Chinese medicine diagnosis was windstrike (wind striking the channels and collaterals) due to liver-kidney yin deficiency and phlegmblood stasis obstruction in the collaterals. He received treatments to reduce the

intracranial pressure and improve the cerebral circulation. He was also given a neuroprotective agent, anticoagulants, and medication to prevent platelet aggregation. No significant improvement was observed following this treatment regime for one week. The CT image of the head revealed an infarction of the left basal ganglia and encephalatrophy. He then received the same Western treatment to improve cerebral circulation and was given a modified Dì Huáng Yĭn Zĭ decoction to be taken as one dose each day. It contained the following ingredients: shú dì 10 g, mài dōng 10 g, yuăn zhì 10 g, fú líng 10 g, shí hú 10 g, bā jĭ tiān 10 g, zhú rú 10 g, chuān xiōng 10 g, shān zhū yú 15 g, shí chāng pú 15 g, wŭ wèi zĭ 6 g, ròu guì 3 g, jī xuè téng 20 g, and dăn nán xīng 8 g. Two weeks later, his speech was more fluent than before. The muscle strength of the damaged area increased to Ⅳ degree and he reported energy improvement. The patient nearly returned to normal after taking more than twenty doses of decoction, with minor changes of the former prescription, following his discharge from the hospital. The formula was modified by removing zhú rú and dăn nán xīng, and adding shuĭ zhì powder 3 g (poured into the decoction).1 Comments: The patient was nearly 70 years old and the kidney became deficient. Deficient yang floated to the outside, combined with the phlegm, and blocked the orifices, which in return, resulted in blurred speech. The flaccidity of the limbs came from liver and kidney yin deficiency; because the liver governs the sinews and the kidney governs the bone. The reason he was treated with Dì Huáng Yĭn Zĭ was to warm and supplement the kidney. Zhú rú and dăn nán xīng enhance the function to reduce phlegm. Jī xuè téng and chuān xiōng promote blood circulation and free the channels.

Guī Lù Èr Xiān Jiāo 龟鹿⼆仙胶Tortoise Shell and Deer Horn Two Immortals Glue Source Text Doctor’s Memo (Yī Biàn, 医便)

Formula Ingredients

Preparation and Administration 1 Shao Shu-juan. Clinical Application of Dì Huáng Yĭn Zĭ 地黄饮⼦临床应⽤举隅. Hubei Journal of Traditional Chinese Medicine. 2005; (27): 1.

Put the lù jiăo, guī băn and rén shēn into a separate bag, place it into a lead jar, and then soak it in flowing water for three days. If a lead jar is not available, please place a large piece of lead under the container that will be used. After three days, seal the container with yellow wax and then put the container in a big pot and boil for seven days and nights. To prevent the two medicinals from being boiled away, remember to add water once a day into the lead jar, five times every 24 hours. Remove the lù jiăo and guī băn when they become crisp. Divide the dregs, named lù jiăo shuāng and guī jiă shuāng and the clear juice for separate storage. Boil the rén shēn and gŏu qĭ in a cuprum pan with 36 bowls of water until there is no water visible. Wrap the two medicinals with a piece of new cloth and twist it until the juice is

collected. Put the dregs back to the pot and boil them again with twenty-four bowls of water. Repeat this process three times until the dregs become tasteless. Mix the juice of lù jiăo and guī băn with that of rén shēn and gŏu qĭ and boil them with gentle fire until it thickens into a jelly-like substance. It is suggested to take it with wine on an empty stomach. The initial dosage is 1.5 qian (4.5 g). After ten days, the dosage can be increased to 6 g (1.5 g more). Following this measure, the dosage can be increased gradually until it reaches 3 qian (9 g). Thereafter, the 9 g dose can be maintained and taken for a long time. (Modern preparation: put all the four ingredients into a lead jar and decoct them together until the jelly is obtained. It is suggested to take the jelly with wine starting from 4.5 g, and gradually increasing it up to 9 g, on an empty stomach.)

Formula Indications Guī Lù Èr Xiān Jiāo is applicable for patterns of kidney yin and yang deficiency with essence and blood insufficiency. The clinical symptoms are marked by emaciation, impotence, spermatorrhea, infertility, dim-vision, and aching and weakness of waist and knees.

Analysis of Fundamental Pattern Pathogenesis The pathogenesis of the corresponding pattern is insufficiency of kidney yin essence and kidney yang. The kidney essence can be consumed either from congenital reasons or from depletion of the acquired diseases as qi and blood are generated by the spleen and stomach, and blood and essence are stored and nourished by the kidney and liver. The root of the disease lies in the kidney, which then affects the body’s yin, yang, qi and blood, so the symptoms mainly stem from the disorder of the kidney system. The

treatment should be to supplement essence and boost marrow, supplement qi and blood, yin and yang at the same time.

Formula Actions Enriches yin and supplements essence, boosts qi and strengthens yang.

Formula Analysis

Unique Combination Features It supplements both yin and yang while taking both qi and blood into account.

Formula Applications 1. Essential pattern differentiation This formula supplements yin and yang, qi and blood, kidney and liver, spleen and stomach at the same time. This clinical pattern is marked by:

2. Modifications

3. Modern applications Guī Lù Èr Xiān Jiāo is currently used to treat maldevelopment caused by dysendocrinia, severe anemia, neuradynamia and hypogonadism when the pattern is differentiated as yin and yang deficiency according to traditional Chinese medicine. 4. Cautions and contraindications This is a pure supplementing formula and is not appropriate for those with a weak spleenstomach system causing poor appetite, loose stools, and so on. However, it can be taken together with Sì Jūn Zĭ Tāng in order to boost the digestion.

Case Studies 1. ITP (idiopathic thrombocytopenic purpura) Ms. Ma, 29 years old, noticed the presence of ecchymosis and petechia on her skin, bleeding gums after her brushing the teeth, and profuse menstruation since the previous year. She was diagnosed with ITP (idiopathic thrombocytopenic purpura) in a hospital and was given a glucocorticoid for a long time without a good effect. Her symptoms recurred frequently, and her platelet count fluctuated between 4×109/L and 50×109/L. She was susceptible to colds and had facial acne. She decided to quit taking the glucocorticoid and turned to traditional Chinese medicine for help. Upon her visit, she complained of lassitude, ecchymosis and petechia of the four limbs, vulnerable to colds, intolerance to cold, poor appetite, poor quality of

sleep, and profuse menstruation. Her urination and bowel movement were normal. Her tongue was pale with a thin, white coating, and her pulse was weak. The current blood platelet count was 3.7×109/L. The pattern was differentiated as deficiency of both qi and blood. The treatment principle was to nourish yin, supplement essence, boost qi, and strengthen yang. She was prescribed Guī Lù Èr Xiān Jiāo composed of guī băn jiāo 250 g, lù jiăo jiāo 250 g, gŏu qĭ zĭ 250 g, hóng shēn 250 g. The formula was prepared by boiling gŏu qĭ and hóng shēn first for about one hour. Then the cooked gŏu qĭ and hóng shēn is chopped into fine pieces and returned to the pan and boil again until a paste is formed. At the same time, put guī băn jiāo and lù jiăo jiāo in a bowl and steamed until they are melted. This was then mixed together with the paste derived from the hóng shēn and gŏu qĭ zĭ and blended evenly close to the fire. A jelly-like substance was finally obtained, which was then stored in a cool and shady place. Two spoonfuls of the formula was taken three times each day. Two weeks later, in a follow-up visit, the platelet count increased to 14×109/L. After one month, the number increased to 36×109/L. After two months, it rose to 78×109/L. There were no longer any ecchymosis, petechia, or gum bleeding noticed. Following several months follow-up, there was no reoccurrence.1 Comments: According to traditional Chinese medicine, purpura is considered to be a blood disorder, termed “blood eruption”, “hematemesis”, “epistaxis” and so on. It is recorded in The Complete Works of [Zhang] Jingyue that, “blood disorders are often caused by fire. Excessive fire forces blood to extravagate. While blood deficiency is often caused by qi disorders; once qi is injured, blood will be lost too.” In this case, all the signs and symptoms, together with the tongue and pulse manifestation, reveal this pathomechanism, qi and blood deficiency, and kidney essence insufficiency. Qi fails to contain the blood, causing this disorder. Treatment should be to

supplement kidney essence, boost qi, and control blood. Guī Lù Èr Xiān Jiāo was prescribed accordingly.

Summary Nineteen representative formulas and twenty-four associated formulas are included in this chapter. They are classified into the following six categories:

● formulas that supplement qi ● formulas that supplement blood ● formulas that supplement both qi and blood ● formulas that supplement yin ● formulas that supplement yang ● formulas that supplement both yin and yang 1. Formulas that supplement qi Sì Jūn Zĭ Tāng, Shēn Líng Bái Zhú Săn, Bŭ Zhōng Yì Qì Tāng, Shēng Mài Săn, Yù Píng Fēng Săn, and Wán Dài Tāng are all representative formulas that supplement qi for patterns of qi deficiency. Besides their common action to supplement qi, they each have their unique features: Sì Jūn Zĭ Tāng is the basic formula to boost qi and reinforce the spleen. It is indicated for spleen-stomach qi deficiency with poor digestion and absorption. Shēn Líng Bái Zhú Săn is used to treat patterns of spleenstomach qi deficiency with excessive dampness accumulation. In addition to its basic qi-supplementing function, it harmonizes the stomach and stops diarrhea. Bŭ Zhōng Yì Qì Tāng is used to reinforce qi and lift up yang. It is used for prolapse of the anus or uterus caused by sunken qi, fever due to qi

deficiency, and symptoms of spleen deficiency due to fatigue. Shēng Mài Săn mainly supplements qi and yin. It also promotes the generation of fluids and arrests sweating and astringes the lung to stop coughing. Therefore, it is used to treat patterns of qi and yin deficiency during the summer or due to chronic coughing that injured lung qi and yin. Yù Píng Fēng Săn reinforces qi, consolidates the exterior, and arrests sweating. It is mainly used to treat the common cold in a deficient body or spontaneous sweating due to exterior deficiency. Wán Dài Tāng is used to supplement the spleen, resolve dampness, and soothe the liver. It is used to treat vaginal discharge due to spleen deficiency and liver qi stagnation with damp accumulation. 2. Blood-supplementing formulas 1 Li Li. Clinical Observation on the Treatment of ITP with Guī Lù Èr Xiān Jiāo 龟鹿⼆仙胶治 疗特发性⾎⼩板减少型紫癜35例临床观察. Chinese Journal of the Practical Chinese with Modern Medicine. 2005; (18): 18.

Sì Wù Tāng, Dāng Guī Bŭ Xuè Tāng, and Guī Pí Tāng all treat patterns of blood deficiency. Among them Sì Wù Tāng, the fundamental formula to supplement and regulate the blood, is often used to regulate menstruation in gynecology departments. It can also be used to treat deficiency and stagnation of ying-blood, insufficiency of chong mai and ren mai, menstrual irregularities, painful menstruation, and so on. Dāng Guī Bŭ Xuè Tāng has a special action to supplement qi and engender blood. It is often used to treat fever due to blood deficiency caused by exhaustion. Guī Pí Tāng is mainly used to supplement qi and blood. It reinforces the spleen and heart and is used to treat patterns of heart-spleen qi and blood deficiency or blood disorders due to spleen deficiency. 3. Qi- and blood-supplementing formulas

Bā Zhēn Tāng and Zhì Gān Căo Tāng are both formulas used to treat patterns of qi and blood deficiency. Bā Zhēn Tāng is the basic formulas used to supplement both qi and blood since it is made up of a combination of Sì Jūn Zĭ Tāng and Sì Wù Tāng. It is therefore commonly used to treat patterns of qi and blood deficiency following a disease. Zhì Gān Căo Tāng is used to nourish yin and blood, reinforce qi, and warm yang. It is often used to treat irregular pulse and palpitation due to yin-blood deficiency and weak yang qi. 4. Yin-supplementing formulas Liù Wèi Dì Huáng Wán, Zuŏ Guī Wán, Dà Bŭ Yīn Wán, and Yī Guàn Jiān are the representative formulas described in this chapter, used to treat patterns of yin deficiency. Each one of them has their own unique properties and features. The first formula, Liù Wèi Dì Huáng Wán, is made up of six medicinals. Half of them are supplements and the other half are draining. Its main function is to supplement the kidney. Its secondary function is to supplement the liver and spleen. Its basic function is to supplement kidney yin. The second formula, Zuŏ Guī Wán, consists of medicinals that purely supplement. It is stronger than Liù Wèi Dì Huáng Wán in terms of supplementing yin. Zuŏ Guī Wán supplements kidney yin and essence; and is therefore used to treat patterns of essence, bone marrow, and kidney yin deficiency. The third formula, Dà Bŭ Yīn Wán, is a fundamental formula used to enrich yin and clear fire. It is often used to treat patterns of liverkidney yin deficiency with excessive ministerial fire. The last formula, Yī Guàn Jiān, specializes in enriching yin and soothing the liver. It is often used to treat gastric or hypochondria pain, acid regurgitation, or bitter-tasting vomit due to liver-kidney yin deficiency with liver qi constraint. 5. Yang-supplementing formulas

Shèn Qì Wán and Yòu Guī Wán are the representative formulas in this section. They are used to treat patterns of kidney yang deficiency. The former is the typical formula used to supplement the kidney and assist yang. It is applicable to patterns of kidney yang deficiency. The latter formula is used to warm and supplement kidney yang and tonify the essence and blood. It is applicable to patterns of kidney yang insufficiency and mìng mén fire insufficiency that fails to warm the earth (spleen). The latter is stronger than the former in supplementing yang for it is only composed of supplementing medicinals. 6. Yin- and yang-supplementing formulas Dì Huáng Yĭn Zĭ and Guī Lù Èr Xiān Jiāo are the representative formulas in this section used to treat patterns of yin and yang deficiency. The former formula is used to treat patterns of yīn fēi because it can enrich yin and yang, open the orifices, and resolve phlegm. The latter formula is often used to treat impotence, seminal emission, and infertility caused by kidney qi, essence, and blood insufficiency. Guī Lù Èr Xiān Jiāo can enrich yin and essence, supplement qi, and assist yang.

Questions 1.Sì Jūn Zĭ Tāng is the foundation of qi-supplementing formulas and Sì Wù Tāng is the foundation of bloodnourishing formulas. Which of these two foundational formulas make up the composition of derivative formulas and how do they account for their corresponding indications? 2.Both Guì Zhī Tāng and Yù Píng Fēng Săn can be used to treat spontaneous sweating. How are they differentiated in terms of clinical applications?

3.Guī Pí Tāng is mainly used to treat palpitations and amnesia, which are disorders of the upper jiao. How is it that it can also be used to treat menstrual bleeding and spotting which are diseases of the lower jiao? 4.What is the special characteristic regarding the dosage of huáng qí and dāng guī within Dāng Guī Bŭ Xuè Tāng? Please explain the reason for this specific dosing. 5.What is the corresponding pattern and indications for Liù Wèi Dì Huáng Wán? What are the principles of its composition and medicinal combinations? 6.What are the differences between Yòu Guī Wán and Shèn Qì Wán in terms of their medicinal combinations and their indications?

Endnotes: [1] 虚者补之 [2] 损者益之 [3] 形不⾜者，温之以⽓ [4] 精不⾜者，补之以味 [5] 善补阳者，必于阴中求阳，则阳得阴助⽽⽣化无穷︔善补阴 者，必于阳中求阴，则阴得阳升⽽泉源不竭 [6] 损其肺者，益其⽓︔损其肾者，益其精 [7] 至虚之病，反见盛势︔⼤实之病，反有羸状 [8] 不治食⽽食⾃消 [9] 培⼟⽣⾦ [10] 惟当以⽢温之剂，补其中，升其阳，⽢寒以泻其⽕则愈。盖 温能除⼤热，⼤忌苦寒之药泻胃⼟⽿！今⽴补中益⽓汤 [11] ⽢温除热 [12] 惟脉不长实有辨⽿，误服⽩虎汤必死 [13] 左归是育阴以涵阳，不是壮⽔以制⽕ [14] 阴常不⾜，阳常有余，宜常养其阴，阴与阳齐，则⽔能制⽕ [15] 是⽅能骤补真阴，以制相⽕，较之六味功效尤捷 [16] 异病同治 [17] 益⽕之源，以消阴翳

[18] 此亦为虚中挟邪滞⽽设尔，若纯虚之证，⽽兼以渗利，未免 减去药⼒，当⽤右归丸或右归饮

CHAPTER 7 Astringent Formulas Astringent formulas consolidate the vital substances (qi, blood, essence and body fluids), and stop their loss by securing leaks. They are mainly composed of astringent medicinals. Qi, blood, essence and body fluids are the vital substances that provide nourishment to the human body. The zang-fu organs perpetually consume, regenerate and replace them. In cases of functional disharmony among the zang-fu organs, depletion of zheng qi, over-consumption, incontinence, or leakage may result in severe depletion of the vital substances. This, of course, leads to poor health which may potentially become life threatening when severe. The therapeutic principle in such cases is to administer astringent medicinals to consolidate the essence and treat the immediate loss. Clinical manifestations vary a lot depending on the course and location of disease, as well as which vital substance that has been lost or damaged. Common symptoms include spontaneous sweating, night sweat, prolonged cough, chronic diarrhea or dysentery, seminal emission, efflux diarrhea, incontinence of urine, menstrual bleeding and vaginal discharge. Based on various clinical applications, astringent formulas in this chapter are divided into five categories:

● formulas that consolidate the exterior and arrest sweating ● formulas that astringe the lung and relieve cough

● formulas that astringe the intestines to rescue from desertion ● formulas that arrest enuresis and seminal emissions ● formulas that stop profuse uterine bleeding and arrest vaginal discharge

Section 1 Formulas that Consolidate the Exterior and Arrest Sweating The formulas in this section are used for deficient patients with wei qi insecurity. Failure of wei qi to defend the exterior and secure yin-fluids results in spontaneous sweating and/or night sweat. They contain astringent medicinals that consolidate the exterior and arrest sweating such as huáng qí, mŭ lì, and má huáng gēn. Mŭ Lì Săn is a representative formula.

Mŭ Lì Săn 牡蛎散Oyster Shell Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind huáng qí, má huáng gēn, and duàn mŭ lì into a course powder. Mix 9 g of the powder together with 30 g of xiăo mài to constitute one dose to be taken as a draft. The formula is prepared as a decoction. It is best to take the decoction warm. (Modern use: the dose of huáng qí, má huáng gēn, and duàn mŭ lì could be reduced according to the clinical presentation while maintaining the original ratios. Combine with 30 g of xiăo mài and decoct the medicinals in water.)

Formula Indications Mŭ Lì Săn is indicated for spontaneous sweating or night sweat in those with a deficient constitution. Symptoms include constant spontaneous sweating that is worse at night, palpitations, easy to become frightened, shortness of breath, vexation, and fatigue. The tongue body is pale or light red and the pulse is thready and weak.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by insufficient wei qi and damaged yin-fluids. Insecurity of the wei qi and exterior deficiency allow yin-fluids to leak and cause spontaneous sweating. Wei qi’s inability to secure the exterior worsens at night. As one falls into sleep, the wei yang descends into the body’s interior leaving the wei qi even more unable to secure the fleshy exterior. The natural abundance of yin during the night exacerbates the imbalance. Excessive sweating depletes the heart yin and causes heart yin deficiency. As a result, the heart yin fails to subdue yang, which results in night sweat. Sweat is the fluid of the heart and excessive sweating consumes heart yin and damages heart qi. Malnourishment of the heart causes palpitations,

propensity to be frightened, shortness of breath, vexation, and fatigue. As seen above, Mŭ Lì Săn treats sweating caused by various pathologies including:

● spontaneous sweating due to yang deficiency ● night sweat due to yin deficiency ● sweating due to deficiency of both qi and yin The source book states that this formula is used to “treat any insufficiency”. A pale tongue body and a thready, weak pulse both indicate qi and yin deficiency. Therefore, the therapeutic principles are to astringe yin and arrest sweating as well as to boost qi and consolidate the exterior.

Formula Actions Astringes yin and arrests sweating, boosts qi and consolidates the exterior.

Formula Analysis

Unique Combination Features This formula simultaneously nourishes and astringes. An emphasis is placed on its astringent function and function to subdue heart yang.

Formula Applications 1. Essential pattern differentiation Mŭ Lì Săn is a common formula used to treat spontaneous sweating and night sweat caused by insecurity of the wei qi at the exterior due to qi deficiency, complicated with damaged yin-fluids and heart yang hyperactivity. This clinical pattern is marked by:

2. Modifications

3. Modern application This formula is often used to treat various sweating problems such as spontaneous sweating and night sweat caused by tuberculosis, autonomic nerve dysfunction, debility after surgery, delivery, diseases caused by exterior qi insecurity due to general deficiency, and hyperactivity of deficient heart yang due to heart yin consumption.

Comparison & Contrast Mŭ Lì Săn vs. Yù Píng Fēng Săn

Section 2 Formulas that Astringe the Lung and Relieve Cough The formula described in this section is indicated for chronic coughing that exhausts the lung qi and yin. Symptoms include cough, labored breathing, spontaneous sweating, and a deficient, rapid pulse. Core medicinals in this section can be divided into two groups. The first group consists of astringent and sour medicinals that secure the lung and stop cough such as wŭ wèi zĭ and wū méi. The second group consists of medicinals that boost qi and nourish yin such as rén shēn and ē jiāo. Jiŭ Xiān Săn is a representative formula.

Jiŭ Xiān Săn 九仙散Nine Immortals Powder Source Text Precious Mirror of Health (Wèi Shēng Băo Jiàn, 卫⽣宝鉴)

Formula Ingredients

Preparation and Administration Grind the medicinals into a powder and for each dose take 9 g with boiled warm water. It is also possible to prepare it as a decoction. The doses of the medicinals are decided according to clinical presentation while considering the original dosage ratios.

Formula Indications Jiŭ Xiān Săn is designed for a pattern of chronic cough caused by lung deficiency. The main symptoms include a chronic, unremitting cough that may be accompanied by labored breathing in severe cases, spontaneous sweating, scanty, sticky phlegm, and a deficient, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis The disease mechanism addressed by this formula is qi and yin deficiency caused by a prolonged cough that has damaged the lung. Chronic coughing consumes and exhausts the lung qi and yin, which in turn, further aggravates coughing. Lung qi deficiency results in lingering coughs (and

even labored breathing in severe cases) along with a deficient pulse. The lung governs the skin and body hair; therefore, insufficient lung qi leaves the striae and interstices open which results in spontaneous sweating. Long-term coughing exhausts lung yin and results in deficient heat which burns the body fluids to produce scanty, sticky phlegm. Astringing the lung to stop coughing; boosting qi and nourishing yin; and directing the qi downward and dissolving phlegm are the appropriate therapeutic principles for this condition.

Formula Actions Astringes the lung, relieves cough, boosts qi and nourishes yin.

Formula Analysis

Unique Combination Features In this formula, astringent, qi-boosting, and yin-nourishing medicinals are all used together. However, there is priority given to the astringents. By combining a large number of astringent medicinals with a small quantity of ascending and dissipating medicinals, this formula simultaneously astringes,

diffuses, descends and ascends. However, its stronger function is to descend and astringe.

Formula Applications 1. Essential pattern differentiation Jiŭ Xiān Săn is a common formula applicable for chronic coughs with lung deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications Jiŭ Xiān Săn is frequently used for the following biomedically defined disorders such as chronic bronchitis, emphysema, pulmonary tuberculosis, bronchial asthma, and pertussis, when the patient shows signs of lung qi and yin deficiency due to chronic and unremitting cough. 4. Cautions and contraindications This formula should not be used for chronic coughs complicated by excessive interior phlegmdrool or with an invasion of exterior pathogens in order to avoid trapping the pathogens within. It is not suggested to take this formula for a long time or in a large dosage. Stop taking it immediately once the cough is relieved.

Case Studies

Cough with panting A 61-year-old male came for an initial visit on July 28th, 1985. For the past 20 years he has suffered with labored breathing and coughing. Although he had been treated by numerous doctors up to this point, he had not had satisfactory therapeutic results. The prescriptions he had taken had only provided symptomatic relief without a cure. Once he stopped taking the medicine, the symptoms returned. Whenever he had a coughing episode he suffered severe breathing difficulties. The breathing became laborious and caused him to inhale more than exhale which produced a wheezing sound from his throat. In order to breathe easier he needed to lift his shoulders up in order to increase ventilation. However, when he did that, it aggravated the symptoms. His face and eyes were puffy. He complained of mental fatigue, lack of strength, weak breathing, frequent urination, and thin unformed stools three or four times each day. His tongue was pale with a thin, white coating. The pulse was thready and slippery. His condition was diagnosed as cough with labored breathing due to deficiency of the spleen, lung, and kidney and was prescribed one bag of Jiŭ Xiān Săn per day. Following the third bag of medicinals, much of the cough and labored breathing was relieved. His spirit improved and his stools thickened which reduced the bowel movements. After another nine bags the cough and labored breathing cleared and his stools returned to normal. There had been no relapse within the following two years of follow-up appointments.1 Comments: Jiŭ Xiān Săn was originally designed for chronic coughs. Yīng sù qiào, wŭ wèi zĭ and wū méi astringe the lung and intestines. Kuăn dōng huā and sāng bái pí relieve cough and labored breathing. Jié gĕng diffuses the lung. Because the lung and large intestine are interiorexteriorly related, normal qi flow of the lung is helpful for the intestines’ normal qi conducting and transmitting process. This formula may be used for chronic

diarrhea or for chronic coughing with labored breathing that depletes zheng qi. 1 Gao Jun-tai. Treating Cough and Diarrhea by Using Jiŭ Xiān Săn 九仙散治咳嗽、泄泻. Journal of Sichuan Traditional Medicine. 1988; 4: 28.

Section 3 Formulas that Astringe the Intestines to Rescue from Desertion The formulas in this section are used for deficiency-cold of the spleen and kidney characterized by chronic diarrhea or dysenteric disorders that, if severe, can lead to fecal incontinence. These formulas are commonly comprised of medicinals that belong within two groups:

● medicinals that astringe the intestines and arrest diarrhea such as yīng sù qiào, ròu dòu kòu, chì shí zhī, and hē zĭ

● medicinals that warm and supplement the spleen and kidney such as bŭ gŭ zhī, ròu guì, gān jiāng, rén shēn, and bái zhú Zhēn Rén Yăng Zàng Tāng and Sì Shén Wán are representative formulas.

Zhēn Rén Yăng Zàng Tāng 真⼈养脏汤Enlightened Master Viscera-Nourishing Decoction Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a coarse powder. Boil 6 g of the powder in water, remove the dregs and take warm before meals. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratio.

Formula Indications This formula is used to treat chronic diarrhea or dysentery due to deficiency-cold of the spleen and kidney. Corresponding symptoms include fecal incontinence, excessive diarrhea or dysentery, abdominal pain that is relieved by pressure and warmth, fatigue, poor appetite or reduced food intake. Usually, the tongue is pale with a white coating. The pulse is deep and slow or slow and thready.

Analysis of Fundamental Pattern Pathogenesis

Zhēn Rén Yăng Zàng Tāng treats intestinal incontinence due to deficiency-cold of the spleen and kidney. The kidney governs the stool and urine and controls the opening and closing of the lower orifices. Because of deficiency-cold of the spleen and kidney, the gate fails to close tightly. This means that deficiency-cold of the spleen and kidney leads to excessive diarrhea, dysentery, or fecal incontinence. If the center qi sinks then there may be rectal prolapse. Because there is deficiencycold of the spleen and kidney, as well as disharmony between qi and blood, abdominal pain responds favorably to local warmth and pressure. The spleen governs transportation and transformation. Reduced food intake and fatigue result from its deficiency. A pale tongue body with a white coating and a thready pulse indicate deficiency-cold of the spleen and kidney. The root of this disease is deficiency-cold of the spleen and kidney, and fecal incontinence due to chronic diarrhea or dysentery is the branch. Urgent treatment of the branch is priority when there is severe loss of essence due to fecal incontinence. The main focus of this formula is to astringe the intestines and rescue from desertion while warming and supplementing the spleen and kidney.

Formula Actions Astringes the intestines and rescues from desertion, warms and supplements the spleen and kidney.

Formula Analysis

Unique Combination Features This formula has the therapeutic action to simultaneously astringe and supplement in order to treat both the root and branch. The emphasis of this formula is to treat the branch. However, it does supplement the spleen and kidney, the root, with emphasis placed on the spleen. It also combines qiregulating medicinals in order to prevent stagnation that can develop when astringing and supplementing medicinals are used.

Formula Applications 1. Essential pattern differentiation Zhēn Rén Yăng Zàng Tāng is frequently used for chronic diarrhea and dysentery in deficiencycold patterns of the spleen and kidney. This clinical

pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency-cold of the spleen and kidney: chronic enteritis, chronic colitis, intestinal tuberculosis, chronic dysentery and dysenteric syndrome. 4. Cautions and contraindications Patients taking this formula should avoid wine, noodles, cold or raw foods, fish, and oily foods. This formula is contraindicated if there is dampheat present along with chronic diarrhea or dysentery.

Associated Formulas Táo Huā Tāng (Peach Blossom Decoction, 桃花汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

[Ingredients]

[Preparation and Administration] Decoct the three medicinals with 7 sheng of water. After the rice is cooked, strain out the liquid. Take 7 ge of the warm decoction with infused chì shí zhī, three times a day. [Actions] Warms the center, astringes the intestines and stops dysentery. [Applicable Patterns] Chronic unremitting dysenteric illness with dark blood and pus in the stool, abdominal pain relieved by local warmth or pressure, a pale tongue, and a slow and weak pulse or faint and thready pulse.

Case Studies Chronic dysentery The initial visit of this 62-year-old male farmer was on February 10th, 1990. One half year ago he suffered from acute bacterial dysentery which was not properly treated. The condition became chronic and unremitting with red and white matter in the stool. Sometimes the stool would look like a heap of white foam or jelly. In addition to the dysentery he also complained of mild, persistent abdominal pain, intolerance to cold and low back soreness. He was observed, upon his initial examination, to have cold extremities and mental fatigue. His tongue had a pale body and a white coating. His pulse was deep, thready, and weak. A microscopic study identified a high white blood cell count.

The case was diagnosed as spleen and kidney yang deficiency impairing the intestine’s ability to maintain its contents. He was prescribed the following formula to be decocted and taken each day in combination with Shēn Líng Bái Zhú Wán (Ginseng, Poria and White Atractylodes Pill, 参苓 ⽩术丸): dăng shēn 10 g, dāng guī 10 g, bái sháo 10 g, gān jiāng 10 g, mù xiāng 10 g, bàn xià 10 g, cāng zhú 10 g, ròu guì 6 g, chì shí zhī 10 g, hē zĭ 10 g, yīng sù qiào 10 g, ròu dòu kòu 10 g, gān căo 6 g. After taking the formulas for 15 days, all of his symptoms were relieved. The formula was then combined with Xiāng Lián Wán (Aucklandia and Coptis Pill, ⾹连丸) for another month. Following this, he was symptom free and had no reoccurrence by the time this article was written.1 Comments: The chronic dysentery in this case was due to a pattern of deficiency-cold of the spleen and kidney. Zhēn Rén Yăng Zàng Tāng was adopted to astringe the intestines and consolidate desertion, warm and supplement the spleen and kidney. Chì shí zhī was added to increase astringency, gān jiāng to warm the center, cāng zhú to dry dampness and fortify the spleen, and bàn xià to dry dampness and harmonize the stomach. It was combined with Shēn Líng Bái Zhú Wán (pills) to fortify the spleen and relieve the diarrhea and to reinforce the zheng qi and consolidate the root.

Sì Shén Wán 四神丸Four Spirits Pill Source Text Summary of Internal Medicine (Nèi Kē Zhāi Yào, 内科摘要)

Formula Ingredients

1 Gao Xian-de, Xu Ming-zhi. Examples of Sucessful Cases by Using Zhēn Rén Yăng Zàng Tāng 真⼈养脏汤治验举隅. Journal of Guiyang College of Traditional Chinese Medicine. 1994; 4: 13.

Preparation and Administration Grind all of the medicinals, except shēng jiāng, into a fine powder. Smash 120g of shēng jiāng and collect the juice by adding a little water. Mix the powder and the juice together, shape the mixture into pills, and let dry. Take 9 g of the pills once or twice per day. At least one dose should be taken at bedtime with lightly salted or warm water that has been boiled. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios.

Formula Indications

Sì Shén Wán is used to treat kidney diarrhea due to yang deficiency of the spleen and kidney. Chief symptoms include fifth-watch (diarrhea at dawn) diarrhea, reluctance to eat or drink, poor digestion and absorption, chronic unremitting diarrhea, abdominal pain, lumbar pain, cold limbs, mental fatigue, and lack of strength. Usually, the tongue is pale with a white and thin coating. The pulse is deep, slow and weak.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by mìng mén fire insufficiency. Insufficient mìng mén fire fails to supply the earth (spleen) with the warmth required for its transformative process. Kidney diarrhea, also named “fifth-watch diarrhea”, is a result. The fifth watch is the time of the day (before dawn) when yin qi is at its peak and the yang is beginning to rise. Because of kidney yang deficiency, the body’s yang qi fails to arrive. Yin qi is not counterbalanced and becomes pathologically overabundant. Mìng mén fire fails to warm the spleen (earth) and the spleen cannot carry out its normal transformative function. As a result, water and grains sink downward instead of being transformed into essence. This same principle can be applied to the pathomechanism of chronic diarrhea. As the spleen is damaged, the patient begins to display a lack of interest in food and an inability to digest what is eaten. Yang deficiency of the spleen and kidney in this pattern can be understood in two ways. First off, yin-cold will congeal and cause abdominal pain, sore low back, and cold limbs. Second, deficient yang fails to form the essence that nourishes the spirit causing mental fatigue and lack of strength to develop. The therapeutic principles are to warm and supplement the spleen and to consolidate the intestines to stop diarrhea.

Formula Actions

Warms the spleen and kidney, consolidates the intestines and arrests diarrhea.

Formula Analysis

Unique Combination Features This formula contains medicinals that are warming, supplementing and astringent. The warming, supplementing medicinals treat the root and the astringent medicinals treat the branch. This formulation addresses both the water and earth elements to supplement the mìng mén and warm the spleen.

Further Clarification According to Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ, 医⽅集解), this formula should be taken with lightly salted or boiled water before bedtime. This follows good reason, as Wang An explained, “if the formula is taken in the early morning, the medicinal effect will be spent and at its lowest point of efficacy by the time night comes. It, therefore, will not be able to protect the body from yin-cold at night.” [1] For this reason, it

has been suggested to the patient to take it just before bedtime in order to offer optimal results.

Formula Applications 1. Essential pattern differentiation Sì Shén Wán is commonly used for fifth-watch diarrhea, diarrhea before dawn caused by mìng mén fire deficiency that fails to warm the earth (spleen), or chronic diarrhea. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency-cold of the spleen and kidney: chronic colitis, intestinal tuberculosis, and irritable bowel movement syndrome.

Comparison & Contrast Sì Shén Wán vs. Zhēn Rén Yăng Zàng Tāng

Continued

Case Studies Transmuted pattern from chronic diarrhea Liu Xing-pu, a friend of the author. Mr. Liu suffered diarrhea that progressed into chronic dysentery accompanied with urinary retention. Seeking treatment for his condition he was diagnosed with water accumulation and prescribed a twelve-ingredient formula containing gān suì and gān căo. Mr. Liu was aware that the combination of gān suì and gān căo was antagonistic. Concerned, he asked the doctor if it was appropriate to use in his deficient condition. The doctor affirmed that it was a classical formula perfectly suited for his condition. Feeling confident, he took the formula.

However, after only one dose, the diarrhea worsened nearing the point of qi desertion. At this point the author of this case was invited to consult on Mr. Liu’s, his friend, condition. Upon examination, the patient appeared weak and all of the pulses in the six positions were deep, thready, and forceless. The pulse at the left chĭ position was floating and hollow, and at the right chĭ position was deep and hidden. His condition was diagnosed as a case of water accumulation due to kidney and mìng mén fire insufficiency. Because the kidney and mìng mén fire were further damaged by the purgative formula, it was necessary to urgently warm mìng mén fire and consolidate the kidney. Sì Shén Wán was prescribed and following one dose, the diarrhea stopped and the urine was excreted. Mr. Liu was then prescribed Zhēn Wŭ Tāng to restore yang and promote water elimination along with other formulas that fortify the spleen and supplement fire. After taking the formulas, the symptoms improved and the patient could eat a large bowl of food at each meal.1 Comments: Chronic diarrhea and dysentery accompanied with urinary retention is thought to be caused by a shortage of fluids. It is due to either water accumulation within the intestines or spleenkidney yang deficiency that fails to transform water. Normally, the therapeutic priority is to arrest diarrhea or dysentery. However, the use of purgatives in a condition of severe deficiency further damaged the yang causing the disease to progress and health to deteriorate. The fact that the diarrhea stopped and there was a smooth flow of urine after one dose of Sì Shén Wán indicates that the disease was caused by kidney mìng mén fire deficiency and water excess. 1 Wen Zai-zhi. Simple Statement of Warm Diseases-Wen’s Medical Records 温病浅说·温氏医案. Ancient Books Publishing House of Traditional Chinese Medicine; 1985.

Section 4 Formulas that Arrest Enuresis and Seminal Emissions Formulas that arrest enuresis and seminal emission with astringent medicinals may be applied to cases of seminal emission, spontaneous seminal emission, and premature ejaculation. They are either caused by kidney deficiency that fails to store the essence or by frequent urination and enuresis that is caused by the bladder’s failure to ensure retention due to kidney qi deficiency. Usually these formulas consist of medicinals that supplement the kidney and consolidate the essence such as shā yuàn jí lí, sāng piāo xiāo, qiàn shí and lián zĭ, and astringents such as lóng gŭ, mŭ lì and lián xū. Clinically, the symptoms of this pattern are similar to those experienced in the pattern of noninteraction between the heart and the kidney. Therefore medicinals that supplement the kidney and calm the mind such as fú shén and yuăn zhì are added accordingly. Jīn Suŏ Gù Jīng Wán and Sāng Piāo Xiāo Săn are two representative formulas.

Jīn Suŏ Gù Jīng Wán ⾦锁固精丸Golden Lock Essence-Securing Pill Source Text Medical Formulas Collected and Analyzed (Yī Fāng Jí Jiĕ, 医⽅集解)

Formula Ingredients

Preparation and Administration Grind the above medicinals into a fine powder. Mix it together with lián zĭ powder and shape into pills. 9 g of the pills constitutes a dose. One dose is swallowed with slightly salted water on an empty stomach 2 to 3 times per day. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios. Add a proper amount of lián zĭ into the decoction.

Formula Indications This formula treats sperm emission due to kidney deficiency that fails to consolidate the essence. The symptoms include seminal emission, spontaneous seminal emission, premature ejaculation, mental fatigue, lack of strength, lumbar pain, and tinnitus. The tongue is pale with a white coating and the pulse is thready and weak.

Analysis of Fundamental Pattern Pathomechanism The pattern that Jīn Suŏ Gù Jīng Wán treats is caused by kidney deficiency. The kidney is the domain of stored essence, of which is secured by an “essence gate”. When deficient, the gate will become weak and unable to contain the essence that it is storing. Leaking essence manifests as seminal emission, spontaneous emission, or premature ejaculation. The kidney is

housed in the lumbar and the ears are the orifice of the kidney. When kidney deficiency causes essence to be consumed, symptoms such as lumbar pain and tinnitus may be observed. Essence deficiency further leads to qi deficiency with symptoms such as mental fatigue, weakness, a pale tongue body and a white coating, and a thready, weak pulse. The proper treatment is to supplement the kidney and consolidate essence.

Formula Actions Astringes the essence and supplements the kidney.

Formula Analysis

Unique Combination Features

This formula combines various medicinals that astringe the essence and consolidate qi. It treats the root and branch simultaneously. However it emphasizes treating the branch by astringing the essence. The root is treated by supplementing the kidney, but is emphasized less.

Formula Applications 1. Essential pattern differentiation Jīn Suŏ Gù Jīng Wán is commonly used to treat a weakened “essence gate” caused by kidney deficiency. This clinical pattern is marked by:

It may also be used to treat abnormal vaginal discharge due to kidney deficiency. 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of kidney deficiency, essential qi

insufficiency, and leaking essence: sexual neurological disorder, chyluria, chronic prostatitis, abnormal vaginal discharge and flooding and spotting. 4. Cautions and contraindications Do not use this formula to treat seminal emission or abnormal vaginal discharge caused by stirring up of the ministerial fire or damp-heat in the lower jiao because of its astringent property.

Case Studies Rŭ yì (overflow of breast milk, 乳溢) A 53-year-old female patient had gradually, over a period of a few months, noticed breast distension and hypergalactosis. She had been able to collect approximately 100-150 ml breast milk every day during the two weeks prior to her consultation. The milk, thin, clear and pale, would secrete spontaneously. During examination there were no obvious masses found on the breast. She also complained of mental fatigue, exhaustion, dizziness, tinnitus, palpitations, eating less, and frequent urination at night. The condition was diagnosed as rŭ yì caused by a pattern of chronic liver constraint that led to deficiency of both spleen and kidney and the failure of the qi to contain the essence. She was prescribed shā yuàn zĭ 12 g, lián xū 10 g, chái hú 10 g, qiàn shí 30 g, duàn mŭ lì (to be decocted first) 30 g, mài yá 30 g, duàn lóng gŭ (to be decocted first) 30 g, huáng qí 30 g, qīng pí 6 g, zhì gān căo 3 g, and hē zĭ 4 pieces to be prepared as a water decoction. The condition resolved after taking 6 doses. The prescription was at times modified according to pattern identification.1 1 He Guo-liang. Treating Rŭ Yì (Overflow of Breast Milk) with modified Jīn Suŏ Gù Jīng Wán ⾦锁固精丸加减治愈乳溢证. New Journal of Traditional Chinese Medicine. 1986; 5: 26

Comments: Both the chong mai (the sea of the blood) and ren mai (the governor of the uterus) are ascribed to the liver and the kidney. The kidney governs reproduction and is the domain of stored essence. When the kidney qi becomes deficient for constitutional reasons or is caused by influences of other diseases, various incontinence disorders, including rŭ yì, occur. In this case Jīn Suŏ Gù Jīng Wán was used to supplement the kidney and astringe the essence. Chái hú and qīng pí were added to move qi and soothe the liver; huáng qí to boost qi and consolidate the chong mai; hē zĭ to astringe breast milk; and mài yá (dry-fried) to terminate lactation. The prescription was proven effective and the disease was resolved. The formula addressed the root and branch simultaneously and serves as a good example of treating different diseases with the same method.

Sāng Piāo Xiāo Săn 桑螵蛸散Mantis Egg Shell Powder Source Text Extension of the Materia Medica (Bĕn Căo Yăn Yì, 本草衍义)

Formula Ingredients

Preparation and Administration Grind all the medicinals into a fine powder. 6 g of the powder constitutes a single dose. Swallow the powder with a decoction of rén shēn before bed. This formula can also be prepared as a decoction and taken before bed by adjusting the medicinals quantities based on the original ratios.

Formula Indications Sāng Piāo Xiāo Săn is indicated for a pattern of both heart and kidney deficiency. Signs and symptoms include frequent urination, turbid urine,

enuresis, spontaneous seminal emission, absentmindedness, poor memory, a pale tongue with white coating and a thready, thin pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by deficiency of both the heart and kidney and failure of the water and fire to interact. The kidney governs water and stores the essence. Therefore, when the essence is not contained due to kidney deficiency and the bladder fails to ensure retention, problems such as frequent urination and enuresis occur. When the essence is not stored and controlled properly due to kidney deficiency, disorders involving seminal emission, spontaneous seminal emission, or turbid colored urine will manifest. The consumption of kidney essence leads to kidney qi deficiency and fails to move upward and interact with the heart. This leads to heart deficiency. Together, these two circumstances cause malnourishment of the spirit and symptoms such as poor memory and forgetfulness. If this is not corrected in time, it will eventually impair the body’s essence, blood, and original qi. This type of deficiency is observed by a pale tongue body, a white tongue coating, and a deficient, weak pulse. The treatment is to harmonize and supplement the heart and kidney, consolidate essence, and arrest emission and urination.

Formula Actions Harmonizes and supplements the heart and the kidney, consolidates essence and arrests emission and urination.

Formula Analysis

Unique Combination Features This formula supplements with astringent flavor, and treats the heart and kidney simultaneously.

Further Clarification Originally, Sāng Piāo Xiāo Săn was prepared as a powder using medicinals in equal proportion. It was advised to be taken together with Rén Shēn Tāng (a decoction of rén shēn 30g). The high dose of rén shēn is used to boost the heart qi and calm the spirit as well as to supplement the original qi and consolidate body fluids.

Formula Applications

1. Essential pattern differentiation Sāng Piāo Xiāo Săn is commonly used to treat deficiency of the heart and kidney. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a heart and kidney deficiency pattern: pediatric frequent urination or enuresis, diabetes mellitus, and neurasthenia. 4. Cautions and contraindications It is not applicable for frequent urination, enuresis, seminal emission, or premature ejaculation caused by damp-heat accumulation in the lower jiao, or frenetic stirring of ministerial fire.

Associated Formulas Suō Quán Wán (Stream-Reducing Pill, 缩泉丸) [Source]

Wei’s Family - Circulated Formulas (Wèi Shì Jiā Cáng Fāng, 魏氏家 藏⽅) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills with the size of a phoenix tree seed using powdered shān yào (dry-fried). 50 pills (6 g) are taken with salted water or salted wine. [Actions] Warms the kidney and dispels cold, consolidates essence and arrests enuresis and emission. [Applicable Patterns] Deficient-cold bladder pattern. Symptoms include: frequent urination, enuresis, aversion to cold in the lower abdomen, a pale tongue, and a deep and weak pulse. Both Suō Quán Wán and Sāng Piāo Xiāo Săn can be used to treat frequent urination or enuresis. Sāng Piāo Xiāo Săn uses astringents to consolidate the essence and arrest enuresis. Suō Quán Wán is used for deficient-cold in the lower jiao. It places more emphasis on warming the kidney and expelling cold with the combination of yì zhì rén and wū yào. Sāng Piāo Xiāo Săn is used for a heart and kidney deficiency pattern. It uses medicinals that promote regulation and supplementation to the heart and kidney such as sāng piāo xiāo, guī băn, lóng gŭ, fú shén, and yuăn zhì, etc.

Comparison & Contrast

Sāng Piāo Xiāo Săn vs. Jīn Suŏ Gù Jīng Wán

Continued

Section 5 Formulas that Stop Profuse Uterine Bleeding and Arrest Vaginal Discharge The formulas in this section are intended for female patients with flooding and spotting or for those with leaking vaginal discharge. Flooding and spotting is due to deficiency of the spleen, which renders it unable to restrain vaginal discharge, and an insecure chong mai. These formulas are typically composed of qi-boosting and spleen-supplementing medicinals such as huáng qí, rén shēn, and bái zhú along with medicinals that stanch bleeding such as duàn mŭ lì, duàn lóng gŭ, and zōng lǚ tàn. If the disorder is caused by the stirring up of fire due to yin deficiency, medicinals that nourish the kidney and liver such as guī băn and huáng băi are used together with medicinals like chūn gēn pí to construct a formula. Vaginal discharge is primarily caused by spleen and kidney deficiency with damp-turbidity pouring downward. In this circumstance, formulas are most often composed of medicinals that supplement the spleen and kidney and astringe such as shān yào and qiàn shí combined with those that drain dampness and remove turbidity such as bái guŏ and chē qián zĭ. Representative formulas include Gù Chōng Tāng, Gù Jīng Wán and Yì Huáng Tāng.

Gù Chōng Tāng 固冲汤Penetrating VesselSecuring Decoction Source Text

Records of Chinese Medicine with Reference to Western Medicine (Yī Xué Zhōng Zhōng Cān Xī Lù, 医学衷中参西录)

Formula Ingredients

Preparation and Administration Decoct in water and take it in the usual fashion. Duàn lóng gŭ and duàn mŭ lì should be decocted for about an hour before adding the other medicinals.

Formula Indications Gù Chōng Tāng is designed for the pattern of spleen and kidney deficiency with insecurity of the chong mai. Uterine bleeding may be profuse or it may routinely spot bleed in an irregular pattern. Profuse menstruation occurs with thin and pale menses, dizziness, cold extremities,

palpitation, shortness of breath, mental fatigue, weakness, weak and aching waist and knees.

Analysis of Fundamental Pattern Pathogenesis This formula treats a pathomechanism involving spleen and kidney deficiency with an insecure chong mai. The chong mai, one of the eight extraordinary channels, is described as the sea of the twelve channels and sea of the blood. Therefore, it is thought of as the root of menstruation and closely related to blood. Chong mai pertains to the yangming channel. Thereby, it receives nutrition from qi and blood generated from the spleen and stomach. When the spleen and stomach fail to provide adequate nutrition to the chong mai, incontinence will occur. The chong mai runs parallel with the foot shaoyin kidney channel. It is supported by the kidney qi and stores excess blood in the liver. When the liver and kidney are deficient, the chong mai will become insecure and manifest symptoms of bleeding, spotting, or profuse menstruation. Since blood loss will overtime result in the deficiency of qi and blood, the menses are often thin and pale and will occur with other related symptoms including palpitation, shortness of breath, dizziness, cold extremities, mental fatigue, aching waist and so on. The pale tongue body and weak pulses are due to qi and blood deficiency. Therefore, the treatment should aim at boosting the qi, fortifying the spleen, supplementing the liver and kidney, securing the chong mai, and containing blood.

Formula Actions Boosts qi, fortifies spleen, and strengthens the chong mai to contain blood.

Formula analysis

Unique Combination Features This formula combines qi-supplementing medicinals with astringent medicinals in order to more effectively stanch bleeding. This is a method of treating the branch in an urgent condition. It uses a large number of astringent medicinals with a smaller amount of medicinals that dissolve stasis and stanch bleeding. The purpose is to stop bleeding without leaving residual blood stasis.

Formula Applications 1. Essential pattern differentiation Gù Chōng Tāng is commonly used to treat flooding and spotting in those with a pattern of spleen and kidney deficiency and chong mai insecurity. This clinical pattern is marked by:

2. Modifications

3. Modern application This formula may be used in the following biomedically defined disorders when the patient shows signs of spleen and kidney deficiency and an insecurity of the chong mai: dysfunctional or postpartum profuse uterine bleeding. 4. Cautions and contraindications It is not suggested for flooding and spotting due to excessive blood heat.

Case Studies Sudden uterine bleeding The patient, a 30-year-old woman, suffered from spontaneous uterine bleeding for two days. When the doctor came to see her, she was unconscious and unable to speak. Her skin was cold all over and her pulses were faint, weak and slow. Judging from this, the doctor worried that the qi, blood and potentially the original yang were going to collapse and immediately prescribed a modification of Gù Chōng Tāng. Bái sháo was removed and 8 qian of rén shēn and 3 qian of wū fù zĭ were added. The bleeding stopped with one bag and her body warmed up completely. Her

spirit also returned. She was prescribed another bag of the formula with bái sháo re-introduced to consolidate the effect.1 Comments: Cold skin and faint, weak, and slow pulses are due to sudden heavy blood loss that depletes qi and blood and indicate that the yang qi may soon collapse once the yin-fluids are exhausted. Bái sháo was removed due to its cold nature. Rén shēn and fù zĭ were added to boost qi and restore yang. Once the bleeding stops, bái sháo will supplement the liver and nourish blood as well as to prevent the dry fù zĭ from impairing yin and blood. The purpose of the first prescription was to prevent qi, blood, and original yang from collapsing and to stop bleeding by boosting qi and restoring yang. The therapeutic principle always follows the pattern variations and is the reason for the quick response.

Gù Jīng Wán 固经丸Menses-Securing Pill Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine powder, sieve and blend together. Use water to form the powder into pills. Take 6 g as a draft twice a day and swallow with warm, boiled water. This formula can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios. 1 Zhang Xi-chun. Records of Chinese Medicine with Reference to Western Medicine. Vol. 1 医学 衷中参西录卷⼀. Xi’an: Shanxi Scientific and Technical Publishers; 2009.

Formula Indications Gù Jīng Wán is designed for flooding and spotting due to yin deficiency and blood heat. The symptoms include flooding and spotting or profuse menstruation that is dark or purple, feverish sensation in the palms and soles,

weakness and soreness in the loins and knees, a red tongue body, and a rapid pulse.

Analysis of Pattern Identification and Treatment The corresponding disorders treated by this formula are mostly caused by liver and kidney yin deficiency and intense ministerial fire that impair the chong mai and ren mai, causing them to push out blood. Qi stagnation and blood stasis due to liver constraint, together with blood heat, result in purpleblack menstrual clots. Yin deficiency results in vigorous fire that leads to a feverish sensation in the palms and soles and weak, sore loin and knees. Red tongue body and a wiry pulse indicate constrained heat. Therefore, the treatment should aim at enriching yin and clearing heat, regulating menstruation, and stanching bleeding.

Formula Actions Enriches yin and clears heat, consolidates the channels and stanches bleeding.

Formula Analysis

Unique Combination Features This formula uses sweet, cold medicinals that nourish and moisten in combination with bitter, cold medicinals that clear heat. The effect to nourish water and restrain fire is better when combined. Cool, cold, and bitter medicinals combine with warm, astringent medicinals to move and disperse qi and control flooding and spotting without leaving residual blood stasis.

Formula Applications 1. Essential pattern differentiation Gù Jīng Wán is commonly used for flooding and spotting or profuse menstruation due to blood heat. This clinical pattern is marked by:

● dark red or purple-black, sticky menses ● red tongue

● wiry, rapid pulse 2. Modifications

3. Modern application This formula may be used in the following biomedically defined disorders when the patient shows signs of yin deficiency and blood heat signs: dysfunctional uterine bleeding, profuse or prolonged scanty uterine bleeding resulted from chronic adnexitis.

Comparison & Contrast Gù Jīng Wán vs. Gù Chōng Tāng

Case Studies

Prolonged scanty uterine bleeding The menses of this 38-year-old female patient would continually bleed and were dark and heavy. Her condition had persisted for half of a month before this medical examination. Her general symptoms included afternoon tidal fever, burning heat sensation in the palms, palpitations, dizziness, insomnia, thirst, vexation, and dull pain in the heels. Her pulses were rapid and deficient. Her tongue body was red and had center cracks. Her condition was diagnosed as liver and kidney deficiency with deficiency fire disturbing the ren mai and chong mai. She was prescribed Gù Jīng Wán with cè băi tàn, dì yú tàn, xiān hè căo, shēng dì tàn, and dì gŭ pí added. After taking the formula the bleeding was stanched and the palpitations, dizziness, and insomnia were alleviated. At that point, cè băi tàn, dì yú tàn, and xiān hè căo were removed and nǚ zhēn zĭ and mò hàn lián were added to the formula to create a second prescription. The patient took six bags of this prescription and it resolved the pattern to cure the condition.1 Comments: The prolonged menses in this case were caused by yin deficiency and flaming, vigorous fire. Therefore, Gù Jīng Wán was applied urgently to treat the branch. Once the bleeding was stopped, astringent medicinals were reduced and Èr Zhì Wán was added to treat the root.

Yì Huáng Tāng 易黄汤Yellow-Transforming Decoction Source Text Fu Qing-zhu’s [Treatise on] Gynecology (Fù Qīng Zhŭ Nǚ Kē, 傅青主 女科)

Formula Ingredients

Preparation and Administration Decoct with water. Note: In the source text, bái guŏ is crushed into pieces and huáng băi is fried with wine before decocting.

Formula Indications Yì Huáng Tāng is indicated for patients with abnormal vaginal discharge due to damp-heat accumulation. Symptoms include excessive yellow, sticky, thick leukorrhea. The yellow discoloration may have the

appearance of dark tea in severe cases. Generally, the tongue body is red and the coating is greasy, yellow.

Analysis of Pattern Identification and Treatment 1 Famous TCM Practitioners’ Cases Compiling Group, The Health Department of Zhejiang Province. Medical Cases Treated by Ye Xi-chun 叶熙春医案. Beijing: People’s Medicinal Publishing House; 1965.

This pattern is caused by kidney deficiency and damp-heat accumulation. The kidney communicates with the ren mai. Therefore, kidney deficiency and heat in the kidney may be a cause of its pathology. Qi fails to promote fluid transformation and the fluids then form into dampness. Pathological dampness sinks downwards, travelling along the channels into the lower jiao and manifests as abnormal yellow, stinky, sticky vaginal discharge. The red tongue body with a yellow, greasy tongue coating indicates interior damp-heat. The treatment should consolidate the kidney and arrest vaginal discharge, clear heat, and dispel dampness.

Formula Actions Consolidates the kidney and arrests vaginal discharge, clears heat and dispels dampness.

Formula Analysis

Unique Combination Features This formula emphasizes supplementation and astringency. It is assisted with the clearing and draining method.

Formula Applications 1. Essential pattern differentiation Yì Huáng Tāng is a representative formula for abnormal vaginal discharge caused by damp-heat accumulation and kidney deficiency. This clinical pattern is marked by:

● yellow stinky vaginal discharge ● yellow greasy tongue coating 2. Modifications

3. Modern application This formula may be used in the following biomedically defined disorders when the patient shows signs of kidney deficiency and damp-heat accumulation: cervicitis, vaginitis, or proteinuria after nephritis.

Summary Within this chapter there are nine important representative formulas,

divided into five categories: ● formulas that consolidate the exterior and arrest sweating

● formulas that astringe the lung and relieve cough ● formulas that astringe the intestines to rescue from desertion ● formulas that consolidate essence and arrest enuresis and emission ● formulas that stop profuse uterine bleeding and arrest vaginal bleeding 1. Formulas that consolidate the exterior and arrest sweating Mŭ Lì Săn is indicated for patients with spontaneous sweating or night sweat due to wei qi and heart yang deficiency. It functions to astringe yin, arrest sweating, boost qi, and consolidate the exterior. 2. Formulas that astringe the lung and relieve cough Jiŭ Xiān Săn is intended for prolonged coughing that leads to lung deficiency and consumption of qi and yin. Symptoms include: shortness of breath, spontaneous sweating, and a deficient weak pulse. 3. Formulas that astringe the intestines to rescue from desertion

Zhēn Rén Yăng Zàng Tāng puts more emphasis on consolidating desertion than warming and supplementation. It is intended for the treatment of prolonged diarrhea or dysenteric disorders due to spleen-kidney deficientcold. Sì Shén Wán warms the kidney and spleen, consolidates the intestines, arrests diarrhea, and is mainly used for fifthwatch diarrhea (diarrhea before dawn) or chronic diarrhea due to spleen-kidney yang deficiency. 4. Formulas that consolidate essence and arrest enuresis and emission Jīn Suŏ Gù Jīng Wán and Sāng Piāo Xiāo Săn both have the effect to consolidate essence and to arrest enuresis and emission. They are commonly used to treat seminal emission, enuresis, and similar conditions. Jīn Suŏ Gù Jīng Wán emphasizes consolidation of the kidney with its astringent flavor and is mainly used for seminal emission due to kidney deficiency. Sāng Piāo Xiāo Săn emphasizes supplementation of the heart and kidney and is used for frequent urination, enuresis, seminal emission, or absent-mindedness due to heart and kidney deficiency. 5. Formulas that stop profuse uterine bleeding and arrest vaginal discharge Gù Chōng Tāng and Gù Jīng Wán are both effective to consolidate the meridians and stanch bleeding. They are used to treat flooding and spotting, or profuse menstruation. Gù Chōng Tāng is mainly used to treat patterns of spleen and kidney deficiency. Gù Jīng Wán is used for patterns of yin deficiency with interior heat. Yì Huáng Tāng consolidates the kidney, arrests abnormal vaginal discharge, clears heat, and dispels dampness. It is primarily used for abnormal vaginal discharge due to kidney deficiency.

Questions

1.Why are supplementing medicinals always included within the formulas of this chapter? What should be observed when prescribing astringent formulas in clinical practice? 2.Both Mŭ Lì Săn and Yù Píng Fēng Săn can be used to treat spontaneous sweating due to wei qi deficiency. What are the differences between the two? 3.Compare the similarities and differences between Jīn Suŏ Gù Jīng Wán and Sāng Piāo Xiāo Săn in terms of formula actions and indications. 4.Compare the similarities and differences between Gù Chōng Tāng and Guī Pí Tāng in regards to their corresponding pattern pathomechanisms, therapeutic principles, and medicinal selections.

Endnotes: [1] 若平旦服之，至夜药⼒已尽，不能敌⼀夜之阴寒故也

CHAPTER 8 Orifices-Opening Formulas Formulas that open the orifices utilize orifices-opening medicinals as their key components. They have the therapeutic actions to open the orifices and resuscitate. They are prescribed to treat blocked orifices and unconsciousness. Patterns of blocked orifices and unconsciousness are mainly caused by exuberant, intense pathogenic qi that obstructs the orifices. They are categorized into two types, heat block and cold block, according to their clinical manifestations. Heat block is primarily due to pathogenic heat invading the pericardium causing phlegm-heat to cloud the heart’s orifice. The therapeutic method used for this condition is to clear heat and open the orifices, which is otherwise referred to as “cool open”. Cold block is mainly due to cold-dampness causing phlegm and turbid pathogenic qi to obstruct the heart’s orifice. The therapeutic method used in this condition is to warm and open the orifices, which is otherwise referred to as “warm open”. Therefore, there are two types of orificesopening formulas:

● cool formulas that open the orifices ● warm formulas that open the orifices One should consider the following issues when applying orificesopening formulas:

First, one should identify whether the pattern is a deficient or an excessive one. When pathogenic qi is excessive, the patient is unconscious with a closed mouth, clenched hands, fecal obstruction, retention of urine, and an excessive, forceful pulse. This is the symptom presentation of an excessive pattern for which orifices-opening formulas may be applied. When there is a desertion pattern due to deficiency, the patient has profuse sweating, cold limbs, faint breathing, flaccid hands, incontinence of urine, an open mouth, closed eyes, and a weak, deficient pulse. In this presentation of a deficient pattern, orifices-opening formulas should not be used - even if the patient loses consciousness. Second, one should identify the nature of the block, either hot or cold, in order to properly choose a corresponding orifices-opening formula. Orifices-opening formulas are not suitable for yangming bowel excess syndromes with unconsciousness and delirium. In this case, cold purgatives are appropriate. In the situation of a yangming bowel excess syndrome where pathogens have invaded the pericardium, one may initially prescribe either an orifices-opening formula or a cold purgative formula. They may also be used together in combination according to the severity of the condition. Third, most of the orifices-opening formulas are aromatic and pungent so they tend to disperse and scurry. Therefore, they should only be used temporarily because prolonged use might consume zheng qi. Clinically, they are mostly used for emergencies and dispensed according to proper dose and treatment regimens. Once the patient regains consciousness, treatment according to pattern differentiation should be applied. It should be noted that some medicinals, such as shè xiāng might be harmful to a fetus and should not be prescribed to pregnant women.

Fourth, orifices-opening formulas are most often prepared as powders and pills and should be taken with warm water or by nasal feeding. They may also be prepared as an injection. Because of their volatility, preparing these medicinals as a decoction is not advisable.

Section 1 Cool Formulas that Open the Orifices Cool formulas that open the orifices are applied to patterns of heat block caused by pathogenic heat invading the pericardium. The signs and symptoms include high fever, vexation and agitation, unconsciousness, delirium, and even convulsive syncope. They are also applied to wind-strike, qi constraint, phlegm syncope and turbid pathogen invasion with heat signs, manifested by sudden fainting and unconsciousness. Common aromatic medicinals used to open the orifices are shè xiāng, bīng piàn, yù jīn, and shí chāng pú. They are usually combined with medicinals that clear heat, drain fire, cool blood and resolve toxins such as shuĭ niú jiăo, huáng lián, huáng qín, and shí gāo. They are also often combined with medicinals that tranquilize the heart and calm the mind such as zhū shā, cí shí, hŭ pò, and zhēn zhū because when heat pathogens invade the pericardium, they often disturb the mind. They may also be combined with medicinals to clear and dissolve phlegmheat such as dăn nán xīng, zhè bèi mŭ, tiān zhú huáng, and xióng huáng as heat pathogenic invasion scorches fluid to develop phlegm. Phlegm accumulation confuses the mind and may either lead to or aggravate unconsciousness. Additionally, they may be combined with medicinals that cool the liver and extinguish wind such as líng yáng jiăo and dài mào because excessive heat induces endogenous wind that manifests convulsion

and syncope. Common formulas in this category are Ān Gōng Niú Huáng Wán, Zĭ Xuĕ Dān, and Zhì Băo Dān.

Ān Gōng Niú Huáng Wán 安宫⽜黄丸Peaceful Palace Bovine Bezoar Pill Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Note: in place of xī jiăo, use (60 g) concentrated shuĭ niú jiăo powder.

Preparation and Administration Grind zhēn zhū, zhū shā, and xióng huáng with water or into an extremely fine powder. Grind huáng lián, huáng qín, shān zhī and yù jīn into

a fine powder. Grind niú huáng, shuĭ niú jiăo, shè xiāng and bīng piàn into powder. Then mix them all together, grind, and sift. Form the powder into honey pills (originally they were wrapped with gold foil), each pill weighing 3g. Take 1 pill once daily. Children under three years old take 1/4 pill once daily, 4-6 years old take 1/2 pill once daily, or as advised by the prescribing physician. Patents including Ān Gōng Niú Huáng Săn, Ān Gōng Niú Huáng capsule and Ān Gōng Niú Huáng suppository should only be used when following the specified instructions.

Formula Indications Ān Gōng Niú Huáng Wán is indicated for a pattern of pathogenic heat invading the pericardium. The symptoms are high fever, vexation, unconsciousness, delirium, stiffness of the tongue and cold limbs. The tongue is red or crimson, and the pulse is rapid and forceful. It is also indicated for pathogenic heat causing internal block, wind strike, unconsciousness, and infantile convulsion.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by pathogenic heat invading the pericardium. When intense heat invades the pericardium in a warm disease pattern, the mind becomes disturbed and there is high fever, vexation, unconsciousness, and delirium. When the internal heat is intense, the fluids are scorched into phlegm. The orifices become blocked by the phlegm which worsens the unconscious condition. The heart opens into the tongue. When heat obstructs the heart’s orifice, the tongue becomes stiff and the patient is unable to speak. Furthermore, the deeper the heat is, the more cold the hands and feet become due to reverse flow of qi. Reverse flow of qi manifests with cold limbs, pathogenic heat causing internal block (including wind strike),

unconsciousness, infantile high fever, and convulsion caused by pathogenic invading the pericardium and phlegm-heat clouding the clear orifices.

Formula Actions Clears heat and resolves toxins, opens the orifices and induces resuscitation.

Formula Analysis

Unique Combination Features This formula combines cool medicinals that clear heat and resolve toxins and those that clear and drain heart fire with aromatic medicinals that open orifices and dispel filth. This combination of clearing and opening yields the effect to expel pathogenic factors. Niú huáng is the chief medicinal. It clears heat in the pericardium, eliminates phlegm and opens the orifices. It makes the heart peaceful in its palace; therefore, this formula is named “Peaceful Palace Bovine Bezoar Pill”.

Formula Applications 1. Essential pattern differentiation Ān Gōng Niú Huáng Wán is a common formula to treat heat block in the pericardium, also a typical cool formula that open the orifice. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of heat block in the pericardium: epidemic type B encephalitis, epidemic cerebrospinal meningitis, toxic dysentery, uremia, cerebrovascular accident, hepatic coma, pulmonary encephalopathy, injury to the skull and brain, high fever and coma caused by infection or toxicity. 4. Cautions and contraindications

This formula should not be taken in doses that are either too large or given for too long because it contains aromatic, cold and toxic medicinals. It should not be prescribed for patients with a greasy and white tongue coating due to cold blocking the orifices. It is prohibited during pregnancy.

Associated Formulas Niú Huáng Qīng Xīn Wán (Bovine Bezoar Heart-Clearing Pill, ⽜黄 清⼼丸) [Source] Teachings on the Treatment of Pox from a Family Lineage of Doctors (Dòu Zhĕn Shì Yī Xīn Fă, 痘疹世医⼼法) [Ingredients]

[Preparation and Administration] Grind niú huáng into a fine powder, grind zhū shā with water into an extra fine power, and grind the other medicinals into power. Then mix all powders and sift. Make pills with honey. Each pill weights 1.5 g or 3 g. Take orally, one or two pills once, two or three times daily. Give an appropriate dose to children. [Actions] Clears heat and resolves toxins, opens the orifices and induces resuscitation. [Applicable Patterns]

Heat block within the pericardium in warm disease. Symptoms include: fever, vexation and agitation, unconsciousness and delirium, infantile high fever and convulsion, and coma and wind-strike. Niú Huáng Qīng Xīn Wán was created by Wan Quan in the Ming Dynasty and was collected in the book Teachings on the Treatment of Pox from a Family Lineage of Doctors. Its action and indications are nearly the same as those of Ān Gōng Niú Huáng Wán, which is based on Niú Huáng Qīng Xīn Wán. Xī jiăo is added to clear the heart, cool blood and resolve toxins. Shè xiāng and bīng piàn are added to aromatically open orifices. Zhēn zhū and jīn bó are added to tranquilize the heart and calm the mind. Xióng huáng is added to help niú huáng dispel filth and resolve toxins. Ān Gōng Niú Huáng Wán is more heavily dosed and has a more powerful action, while Niú Huáng Qīng Xīn Wán is milder to clear heat and open orifices, dispel filth, and calm the mind. It is applied to mild heat block.

Case Studies 1. Heat pathogen invading the pericardium The patient, a 45-year-old female, suffered a high fever over the past seven days, with a body temperature of 38 to 40°C. The fever was followed by chills. It became worse with time and was complicated by delirium and confusion. She has even fainted while using the toilet. Both Western drugs and Chinese medicinals had no remedial effect. One pill of Ān Gōng Niú Huáng Wán was given to clear the heart and induce resuscitation as it was caused by heat pathogen invading the heart channel. After taking the pill, the body temperature started to drop in the evening. One Zhì Băo Dān pill was applied the next morning to clear heat, resolve toxins, calm the mind and drain the orifices. Afterwards the body temperature dropped to 35.7°C and

she began to sweat. Niú Huáng Qīng Xīn Wán was used to extinguish wind and strengthen body. The patient then finally recovered completely.1 Comments: This disease was caused by a heat pathogen invading the heart channel. The heart is the residence of the mind, speech is the voice of the heart, and the heart dominates blood and blood vessels. When exuberant heat invades the heart channel the mind becomes confused. Ān Gōng Niú Huáng Wán was applied immediately to clear the heart and induce resuscitation. Once the heat was cleared, Zhì Băo Dān was used because it is not very cold. Then finally, the fever cleared after she broke a sweat. To prevent impairment of qi and blood, Niú Huáng Qīng Xīn Wán was applied to boost qi and nourish blood, suppress fright and calm the mind, and dissolve phlegm and extinguish wind. 2. Vascular dementia 1 Xi Yuan Hospital of Academy of TCM. Medical Discourses of Yue Mei-zhong岳美中医话集. China Ancient Books Publishing House; 1981. p. 112.

Mr. Zhou, a 69-year-old male, had his initial visit on April 6th, 1999. His ability to care for himself had started to diminish with increasing disorientation. Since the winter of 1998, his memory of recent events became poor. He felt vexed and agitated, suffered insomnia, and found walking difficult. He visited the department of Neurology and Geriatrics where an MRI of his head was performed. The results of the MRI indicated multiple basal ganglia infarctions. A diagnosis of multiinfarct dementia (MID) was defined and Dihydroergotoxine Mesylate Tablets and Ginkgo Biloba Extract tablets were prescribed. When he visited the hospital, his condition was getting worse. He was totally unable to care for himself, he couldn’t recognize people, and he suffered vexation and agitation. The condition of stool and urine was not clear. An MMSE (mini-mental state exam) and HIS were performed with scores of 11 and 6 respectively. His

tongue was not examined and his pulse was wiry and superficial. It was a pattern of phlegm-fire disturbing the heart, blood stasis in the blood vessels of the brain, and dysfunction of the spirit. The therapeutic method was to clear the heart and dissolve phlegm, activate blood and drain the channels. Ān Gōng Niú Huáng Wán pills were prescribed. One half pill was to be taken every day for 10 days. He was also given a formula in addition. By the time 2 pills of Ān Gōng Niú Huáng Wán were taken, the vexation and agitation was significantly relieved. His mind began to have occasional clarity and he started to sleep better. Ten days later, he became oriented; he could greet his family, eat by himself, and take care of himself most of the time. The MMSE was performed again and this time he received a score of 18. After this achievement, two to three pills of Ān Gōng Niú Huáng Wán were used every 2 weeks for 3 months. Thereafter all of the symptoms were significantly relieved. One year later, he was stable and he scored 22 on the MMSE exam.1 Comments: Ān Gōng Niú Huáng Wán clears heat, resolves toxins, eliminates phlegm, and opens the orifices. It is applied for block caused by heat-toxins and phlegm-heat. Vascular dementia is mainly caused by obstruction of the brain-collaterals due to a complex of heat, blood stasis, and phlegm. Therefore, it is very important to expel phlegm, remove blood stasis, clear fire, and open the orifices. Ān Gōng Niú Huáng Wán is properly suitable for this pattern. Nevertheless, one should pay attention to its dose and duration when applying it. Ān Gōng Niú Huáng Wán is made up of drastic, aromatic medicinals that have observable effects. These include potential side effects when used improperly and possible interactions with other medications. Therefore, it is not advised to take it for more than 2 weeks at a time during one course of treatment. If the patient needs more pills, a two or three week interval must be considered.

Zĭ Xuĕ Dān 紫雪丹Purple Snow Elixir Source Text Arcane Essentials from the Imperial Library (Wài Tái Mì Yào, 外台秘 要)

Ingredients

1 Yang Bo-can, Jiang Xiao-bei. New Application of Ān Gōng Niú Huáng Wán 安宫⽜黄丸新⽤. New TCM. 2003; 35(6): 72.

Note: Shuĭ niú jiăo is used in place of xī jiăo. Gold is no longer used.

Preparation and Administration First crush shí gāo, hán shuĭ shí, huá shí and cí shí and decoct them in water three times. Discard the dregs. Then, add xuán shēn, mù xiāng, chén xiāng, shēng má, zhì gān căo and dīng xiāng and decoct for another three

times. Finally, filter the decoction and concentrate it into an extract. Second, grind máng xiāo (5 kg) and xiāo shí (950 g) and blend them with the above extract. Then mix, dry, and further grind the mix into powder. Third, grind líng yáng jiăo, zhū shā, shè xiāng, and shuĭ niú jiăo into powder. Zhū shā is ground using water and the amount of shè xiāng is 1.5 g. Finally, mix all the powders, sift the mixture and bottle in 1.5 g increments. Ingest 1.5–3 g twice daily. Children under one year old take one dose of 0.3 g. Children aged 2–5 years old take one daily dose that is equal to 0.3 g multiplied by their age. Children 5 years old and above should take an appropriate dose.

Formula Indications Zĭ Xuĕ Dān is indicated for heat invading the pericardium and excessive heat generating wind. The symptoms are high fever, vexation and agitation, unconsciousness and delirium, convulsion, syncope, thirst, drinking a lot, scorched lips, dry tooth, dark urine, and constipation. The tongue is crimson with a dry, yellow coating, and a wiry, forceful pulse. Zĭ Xuĕ Dān is also indicated for infantile convulsion due to excessive heat.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by heat invading the pericardium and excessive heat generating wind. Unconsciousness, vexation and agitation, and delirium result from heat disturbing the spirit. Syncope and convulsion result from excessive heat generating wind. Thirst, drinking a lot, scorched lips, and dry tooth result from heat consuming fluid. Infantile convulsion due to heat is a sign of pathogenic heat block and internal stirring of liver wind. The therapeutic method is to clear heat with cold, open the orifices with aroma, extinguish wind, and calm the mind.

Formula Actions Clears heat and opens the orifices, extinguishes wind and arrests convulsion.

Formula Analysis

Continued

Unique Combination Features This formula combines heavy minerals, sweet, salty, cold, aromatic, heat-clearing, fire-draining, orifice-opening, resuscitation-inducing, and

body fluid-protecting medicinals. It benefits the heart and liver, clears heat, and opens the orifices to extinguish wind and arrest convulsions. It is named purple snow because its color is purplish and its property is as cold as frost and snow.

Formula Applications 1. Essential pattern differentiation Zĭ Xuĕ Dān is commonly indicated for heat invading the pericardium and excessive heat generating wind. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of excessive heat invading the pericardium and exuberant heat stirring wind: various febrile and infective diseases such as epidemic cerebrospinal meningitis, end-stage of

encephalitis B, septicemia period of severe pneumonia, scarlatina, purulent infective diseases, hepatic coma, infantile convulsion and infantile measles. 4. Cautions and contraindications This formula should not be taken excessively because it may consume zheng qi and should be discontinued once the symptoms are relieved. It is not appropriate to use for weak patients with qi deficiency and is prohibited during pregnancy.

Associated Formulas Xiăo Ér Huí Chūn Dān (Children’s Return-of-Spring Elixir, ⼩⼉回春 丹) [Source] Medicinal Statements from Hall of Respect Processing (Jìng Xiù Táng Yào Shuō, 敬修堂药说) [Ingredients]

[Preparation and Administration]

Prepare into pills, and each pill weights 0.09 g. Take one pill each time when under one year old and take two pills each time when aged between 1– 2 years old, two or three times daily. [Actions] Opens the orifices and arrests fright, clears heat and dissolves phlegm. [Applicable Patterns] Acute infantile convulsion due to heat clouding the heart’s orifice. Symptoms include: fever, vexation and agitation, unconsciousness, convulsion, belching and vomiting, night crying, vomiting of milk, wheezing and cough, and abdominal pain and diarrhea. Both Zĭ Xuĕ Dān and Xiăo Ér Huí Chūn Dān can clear heat, open the orifices, extinguish wind and arrest convulsions. They both are indicated by high fever, vexation, agitation, unconsciousness, convulsion, a red tongue, and an excessive pulse. Zĭ Xuĕ Dān contains shuĭ niú jiăo (xī jiăo was originally used), shí gāo, hán shuĭ shí, huá shí, xuán shēn and shēng má. These medicinals are good at clearing heat and resolving toxins in warm disease cases of heat blocking the pericardium with exuberant heat stirring wind. Xiăo Ér Huí Chūn Dān is indicated for acute infantile convulsions caused by external pathogenic contraction and phlegm-heat blocking the heart orifice. The pathomechanism is characterized by a complex of heat, phlegm, wind, and convulsion. It combines niú huáng, tiān zhú huáng, dăn nán xīng, chuān bèi mŭ, and fă bàn xià to clear heat and eliminate phlegm. These medicinals are good at arresting convulsions and dissolving phlegm. Xiăo Ér Huí Chūn Dān is the formula to treat acute infantile convulsion based on experience.

Zhì Băo Dān 至宝丹Supreme Jewel Elixir Source Text Fine Formulas of Su and Shen (Sū Shĕn Liáng Fāng, 苏沈良⽅)

Formula Ingredients

Note: Use concentrated shuĭ niú jiăo powder in place of xī jiăo. Soak ān xī xiāng in wine, cook with water, filter, and use exactly 1 liang (30 g). The original formula used fifty pieces of gold and silver foil, but they are rarely used today.

Preparation and Administration First, grind dài mào, ān xī xiāng, and hŭ pò into a fine powder. Grind zhū shā and xióng huáng with water. Grind shè xiāng, niú huáng, bīng piàn and shuĭ niú jiăo into powder. Second, mix all the powders, filter, and then prepare them into 3 g pills using honey.

Take one pill once daily orally. Children take it by reducing the medicinal quantities appropriately based on the original ratios. It can also be prepared as a powder and bottled in 2 g dosages. Take 2 g once daily orally. For children less than 3 years old take 0.5 g once daily. Children between 4– 6 years old take 1g once daily. Otherwise the dosage may follow the doctor’s advice.

Formula Indications Zhì Băo Dān is indicated for phlegm-heat blocking the pericardium. The symptoms are unconsciousness, delirium, high fever, vexation, agitation, excessive phlegm, and panting. The tongue is red with a yellow, greasy coating and a slippery, rapid pulse. Zhì Băo Dān is also indicated for wind-strike, summerheat-strike, infantile syncope, and convulsions caused by internal phlegmheat block.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by phlegm-heat blocking the pericardium. Unconsciousness, vexation and agitation, delirium, and fever result from phlegm-heat disturbing the mind. Wheezing and panting result from phlegmdrool obstructing the airways. A red tongue body and a yellow, greasy coating are signs of internal phlegm-heat obstruction. Infantile convulsions and wind-strike share the same pathomechanism. The therapeutic method is to remove turbidity, open orifices, clear heat, and resolve toxins.

Formula Action Removes turbidity, opens the orifices, clears heat and resolves toxins.

Formula Analysis

Unique Combination Features Zhì Băo Dān is characterized by the combination of aromatic medicinals that remove turbidity and open the orifices with cold medicinals that clear heat and resolve toxins. The aromatic medicinals provide the main medicinal effect of the formula while the cold medicinals assist by clearing heat. Zhì Băo Dān is composed of expensive precious medicinals and can achieve incredible effects in an emergency situation, so it carries the name

“Supreme Jewel Elixir”.

Formula Applications 1. Essential pattern differentiation Zhì Băo Dān is commonly indicated for phlegm-heat blocking the pericardium. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of phlegm-heat blocking the pericardium: epidemic cerebrospinal meningitis, type B encephalitis, toxic dysentery, uremia, cerebrovascular accident, hepatic coma, coronary heart disease, angina pectoris, epilepsy, and so on. 4. Cautions and contraindications

This formula contains a lot of aromatic and pungent medicinals and may consume yin and body fluid. Therefore, it should not be applied to the patient with unconsciousness and delirium due to excessive yang and deficiency of yin. It is prohibited during pregnancy.

Associated Formulas Xíng Jūn Săn ( The March Powder, ⾏军散) [Source] Viewpoint About Acute Gastroenteritis from the Lay Buddhist Sui-Xi (Suí Xī Jū Huò Luàn Lùn, 随息居霍乱论) [Ingredients]

[Preparation and Administration] Grind into fine powder and mix together, bottle it in porcelain, and seal with wax. Take 0.3–0.9 g each time, two or three times daily with cool water. [Actions] Dispels filth and resolves toxins, clears heat and opens the orifices. [Applicable Patterns] Summerheat-strike. Symptoms include: vomiting and diarrhea, abdominal pain, restlessness, dizziness, unconsciousness, aphtha, sore throat, and nebula due to wind-heat.

Both Zhì Băo Dān and Xíng Jūn Săn can clear heat, open orifices, treat dizziness, unconsciousness, and so on. Zhì Băo Dān combines aromatic medicinals to remove turbidity and open the orifices with cold medicinals to clear heat and resolve toxins. Its primary function is aromatic and secondary is heat clearing. It is indicated for excessive heat and phlegm blocking the pericardium. Xíng Jūn Săn combines aromatic medicinals that open tbe orifices, dispel filth, resolve toxins, and calm the mind with heavy sedatives. Its primary function is to open the orifices and dispel filth and secondary is to induce resuscitation and resolve toxins. It is applied to either summerheatfilth or counterflow qi clouding the clear orifices. Because it was the common formula used by the army to treat summerheat-strike, malaria, leprosy, and environmental inadaptability, it is named “The March Powder”.

Comparison & Contrast Ān Gōng Niú Huáng Wán vs. Zĭ Xuĕ Dān vs. Zhì Băo Dān

Case Studies Pathogen entering the pericardium

The patient, surnamed Wang, contracted a warm pathogen via the nose and passed into the lung. The pathogen then reversely transmitted to the pericardium disturbing the monarch (heart). Consequently, the mind became confused and the pathogen spread to cloud the orifices and block the collaterals. Medicinals that eliminate phlegm, subdue fire, and regulate qi were applied to this case without success. Doctor Ye remembered an important passage recorded in the Treatise on Cold Damage that describes “light pathogens mostly affect the upper and middle jiao. The lung is located in the uppermost position of the internal organs. When the pathogen enters the pericardium there may be stagnation of qi and blood. This should be treated by aromatic medicinals that dispel filth and open the orifices”. From this, he deduced that Zhì Băo Dān, recorded in Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和 剂局⽅), might work.1 Comments: Ye Tian-shi produced a system of classification that works as a guideline for all kinds of warm diseases. Warm pathogens may initially invade the lung when entering the upper jiao, but then reversely transmit into the pericardium. Additionally, it is recorded in the Treatise on Cold Damage that light pathogens mostly affect the upper and middle jiao. In this case, light, warm pathogens entered through the nose, accumulated in the lung and then reversely transmitted into the pericardium causing the stagnation of qi and blood. Therefore, the medicinals that eliminate phlegm, subdue fire, and regulate qi were not effective. Aromatic Zhì Băo Dān used to disperse filth and to penetrate and open the orifices did work.

Section 2 Warm Formulas that Open the Orifices Warm formulas that open the orificies are used to treat cold block caused by wind-strike, coldstrike, qi constraint, and phlegm syncope. The diseases manifest with sudden fainting, locked jaw, unconsciousness, a white tongue coating, and a slow pulse. Common aromatic medicinals are sū hé xiāng, ān xī xiāng, bīng piàn and shè xiāng. They are usually combined with interior-warming and qi-moving medicinals such as bì bá, xì xīn, chén xiāng, dīng xiāng, tán xiāng and so on. The common representative formula is Sū Hé Xiāng Wán.

Sū Hé Xiāng Wán 苏合⾹丸Storax Pill a.k.a. Chī Lì Jiā Wán (吃⼒伽丸) Source Text Universal Assistance Formulas, excerpt from Arcane Essentials from the Imperial Library (Guăng Jì Fāng, Wài Tái Mì Yào, 广济⽅录⾃外台秘 要)

Formula Ingredients

1 Ye Tian-shi. Case Records As A Guide to Clinical Practice临证指南医案. Shanghai: People’s Publishing House; 1959. p. 323.

Note: 65 g shuĭ niú jiăo is used in place of xī jiăo.

Preparation and Administration First, grind zhū shā with water. Then grind ān xī xiāng, rŭ xiāng, mù xiāng, xiāng fù, bái tán xiāng, dīng xiāng, chén xiāng, bì bá, hē zĭ pí, shè xiāng, bīng piàn, and shuĭ niú jiăo into powder. Second, mix all the powders together and grind once more. Then sift the powder. At this time, warm the sū hé xiāng with water. Third, make pills using honey and water dried at a low temperature. Or prepare the pills using only honey. Each pill should weigh 3 g. Take 1 pill once daily with warm water. The dosage should be reduced for children. The formula may be administered nasally in those patients who are unconscious or unable to swallow the pills.

Formula Indications

Sū Hé Xiāng Wán is indicated for cold block. The symptoms are sudden fainting and locked jaw, unconsciousness, a white tongue coating, and a slow pulse. It is also indicated for sudden pain in the heart and abdomen as well as syncope due to cold block.

Analysis of Fundamental Pattern Pathogenesis This is a pattern caused by cold block. Symptoms of sudden fainting, locked jaw and unconsciousness are caused by obstruction and clouding of the clear orifices due to qi block resulting from an accumulation of coldphlegm and turbidity. The white tongue coating and slow pulse are caused by excessive internal cold. Chest pain is caused by congealed cold accumulation in the chest causing stagnation of qi and blood. Intolerable, distending epigastric and abdominal pain is caused by pathogenic accumulation in the middle jiao causing qi constraint. Cold and turbidity obstructing the orifices is the pathomechanism causing this pattern. The appropriate therapeutic method is to open the orifices using aromatic medicinals combined with medicinals that warm the interior, dissipate cold, move qi, activate blood, dispel filth and resolve turbidity, because pathogens of cold, qi constraint, filth and turbidity are involved.

Formula Actions Aromatically opens the orifices, moves qi and relieves pain.

Formula Analysis

Unique Combination Features Sū Hé Xiāng Wán contains many aromatic medicinals that work to dispel filth and open the orifices. It also moves qi, warms the center, and relieves pain. Medicinals that supplement qi, astringe, cool, and are heavy are used as paradoxical assistants. They help prevent too much dispersion caused by the warm, acrid medicinals.

Formula Applications 1. Essential pattern differentiation Sū Hé Xiāng Wán is a typical warm formula that opens the orifices. It is also a common formula to treat cold block, or pain in the heart and abdomen

caused by qi stagnation due to congealing cold. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of either cold block or qi stagnation due to congealing cold: acute cerebrovascular disease, hysterical syncope, epilepsy, senile dementia, epidemic type B encephalitis, hepatic coma, coronary heart disease, angina pectoris, and myocardial infarction. 4. Cautions and contraindications This formula is commonly used in emergencies and for relieving pain. It should not be taken for a long time because it may consume zheng qi. It is not applicable for desertion or heat block. This formula contains a lot of aromatic and acrid medicinals and may damage the fetus, so it is prohibited during pregnancy.

Associated Formulas

Guàn Xīn Sū Hé Wán (Coronary Heart Storax Pill, 冠⼼苏合丸) [Source] Chinese Pharmacopoeia (Zhōng Guó Yào Diăn, 中国药典) [Ingredients]

[Preparation and Administration] Grind rŭ xiāng, tán xiāng and mù xiāng into fine powder and sift; grind bīng piàn into powder; then mix all the powders and sift. Put sū hé xiāng in warm honey and mix well. Then add in all the ground medicinals and make 1000 pills. Take 1 pill 1-3 times daily or by doctor’s instruction. Chew the pill and swallow it. [Actions] Regulates qi, relaxes the chest, and relieves pain. [Applicable Patterns] Chest bi caused by qi stagnation due to congealing cold and blockage of heart vessels. Symptoms include: chest distress, precordial pain, coronary heart disease and angina pectoris. Zĭ Jīn Dìng ( Purple Colden Pastille ,紫⾦锭) [Source] Further Discourses on Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹 溪⼼法) [Ingredients]

[Preparation and Administration] Grind zhū shā and xióng huáng with water, grind shān cí gū, wŭ bèi zĭ, hóng dà jĭ into powder, grind shè xiāng into powder, then mix all of the medicinal and sift. Steam 320 g of glutinous rice flour with water and mix in the other medicinals. Prepare as pastille, and dry it at a low temperature. Take 0.6–1.5g once daily. For external application, mix with vinegar and apply in the affected area. [Actions] Dispels filth, resolves toxins, resolves phlegm, opens the orifices, and relieves swelling and pain. [Applicable Patterns] Epidemics in the summer, phlegm syncope. Symptoms include: abdominal distension and pain, nausea and vomiting, diarrhea, dysentery, a moist tongue, and a thick, greasy or dirty, greasy coating. External use for: furuncles, sores, swellings, insect bites, mumps, erysipelas, and acute throat troubles. Both Sū Hé Xiāng Wán and Guàn Xīn Sū Hé Wán open the orifices with their aromatic properties. They also move qi and relieve pain and may be applied for coronary heart disease, angina pectoris and other similar pathologies caused by qi stagnation due to congealing cold and excessive phlegm.

Sū Hé Xiāng Wán is composed of many medicinals and has a stronger action to open the orifices, move qi, dispel cold and relieve pain. It is widely used to open the orifices obstructed by cold, turbidity, filth and qi constraint. Guàn Xīn Sū Hé Wán is based on Sū Hé Xiāng Wán and only contains five medicinals. It has the action to open the orifices, move qi, and promote blood circulation. It was made for coronary heart disease and angina pectoris; however, it also effectively eases the chest and relieves pain in chest distress with a chocking sensation. Zĭ Jīn Dìng is good at resolving phlegm, opening the orifices, dispelling filth, resolving toxins, and relieving swelling and pain. It is used not only for nausea, vomiting and diarrhea caused by turbid phlegm accumulation, but also for sores, furuncles and swellings.

Case Studies 1. Drum belly Liu, a 36-year-old female teacher, came in for an initial visit on October 16th, 1965. Her abdomen had expanded over the previous week. Yet, when palpated, it felt soft. She had a poor appetite, clean tongue coating, slippery pulse, and emotional constraint. The therapeutic method determined was to soothe the disorderly flow of qi. Two pills of Sū Hé Xiāng Wán was prescribed along with a formula consisting of chái hú 6 g, dāng guī 6 g, zhĭ qiào 5 g, dà fù pí 9 g, qīng pí 5 g, wú zhū yú 2 g, guăng mù xiāng 5 g, shā rén 3 g, shā rén qiào 3 g, xiāng yuán pí 12 g and sū gĕng 9 g. Half a month later, she came to the hospital for another issue and reported that her abdominal expansion resolved after two packs of the medicinal.1 Comments: This disease was caused by binding constraint of the seven emotions which led to her abdominal expansion. Qi constraint was indicated

because the abdomen was soft when pressed. Sū Hé Xiāng Wán is composed of many aromatic medicinals with the actions to dispel filth, resolve turbidity and move qi. Therefore, it was combined with the formula to soothe the liver and regulate qi. After two packs the symptoms were eliminated. 2. Vertex headache Wang, a 65-year-old male suffered with a cold vertex headache for over four decades. The intensity of the headache varied day to day. He had an aversion to cold and wind, preference to warmth and pressure, stiff neck when the weather was cold, a pale tongue body, a white coating, and a thin, choppy pulse. He wore a heavy cap during the spring and winter, a light cap in the summer, and slept with a cover over his head at night. His condition was diagnosed as a jueyin headache and Wú Zhū Yú Tāng combined with Sū Hé Xiāng Wán was prescribed. The cold pain was relieved significantly 30 minutes after taking the formulas and the headache disappeared the next day. He was suggested to take one pack each day for a week. Thereafter, the headache was gone completely. 2 1 Zhang Zong-liang. Excerpt from Lian Jian-wei, Fine Formulas from Generations of Famous Physicians 连建伟·历代名⽅精编. Zhejiang: Sciences and Technology Publishing House, 1987. p. 226. 2 Zhang Fang-fei. The Use of Sū Hé Xiāng Wán to Treat Pain苏合⾹丸治疗痛证验案举隅. Liaoning: Traditional Chinese Medicine Magazine. 1988; (1): 31.

Comments: Sū Hé Xiāng Wán contains aromatic medicinals that move qi, dispel cold, and dispel blood stasis. It has a significantly strong action to dispel cold and is therefore a key formula for cold conditions. It removes congealing cold and constrained qi in the zang-fu organs and channels, as well as the qi and blood levels. Therefore, it is effective for all kinds of qi constraint, blood stasis, and congealing cold. The patient had significant aversion to wind and cold which clarified that this was a case of jueyin

headache with cold. Furthermore, congealing cold leads to pain from qi constraint and blood stasis. The patient likes warmth and pressure which infers a cold pattern complicated by qi stagnation and blood stasis. Wú Zhū Yú Tāng and Sū Hé Xiāng Wán were applied. They not only warmed the jueyin, but they also moved qi with their aromatic qualities, dispelled blood stasis, and dredged the collaterals.

Summary There are 4 formulas within the orifices-opening formulas chapter. They are categorized as either formulas that cool and open the orifices or those that warm and open the orifices:

● cool formulas that open the orifices ● warm formulas that open the orifices 1. Cool formulas that open the orifices Ān Gōng Niú Huáng Wán, Zĭ Xuĕ Dān and Zhì Băo Dān are common formulas in this category. Together they are referred to as the “three treasures”. While they share a common ability to treat heat block, there are differences among them in application. Ān Gōng Niú Huáng Wán is indicated for heat invading the pericardium marked by unconsciousness and delirium. It is good at clearing heat, resolving toxins and eliminating phlegm. Zhì Băo Dān is indicated for heat block marked by unconsciousness. It is good at opening the orifices and dispelling filth with its aromatic quality. Zĭ Xuĕ Dān is indicated for either heat invading the pericardium or excessive heat generating wind marked by unconsciousness with syncope and convulsions. It is good at extinguishing wind and arresting convulsions.

It has mild effect to resolve toxins compared to Ān Gōng Niú Huáng Wán, and a mild effect to open the orifices compared to Zhì Băo Dān. 2. Warm formulas that open the orifices Sū Hé Xiāng Wán is a common formula in this category indicated for cold block. It can open the orifices and dispel filth, and is good at moving qi, warming the center and relieving pain. It is effective for cold block marked by unconsciousness and qi stagnation due to congealing cold marked by precordial and abdominal pain.

Questions 1.How do you properly select an orifices-opening formula through a clear differentiation of unconsciousness in terms of deficiency or excess? 2.Compare the “three treasures” in terms of their individual indications and actions. 3.Why does the formulas Sū Hé Xiāng Wán use the combination of bái zhú and hē zĭ?

CHAPTER 9 Mind-Calming Formulas Mind-calming formulas utilize mind-calming medicinals as their key components and have the therapeutic actions to calm and tranquilize the mind. They are used to treat the diseases of mind disturbance. The diseases of mind disturbance are principally manifest by (severe) palpitations, insomnia, forgetfulness, vexation and agitation, fright and mania, and so on. The heart stores the spirit, the liver stores the soul, and the kidney stores the will. Therefore, mind disturbance is mainly attributed to imbalance of yin and yang in the heart, liver, or kidney or dysfunctions among the three. The three main causative factors that disturb the mind are:

● emotional stimulation, such as terror, that results in an unstable spirit and soul

● liver stagnation due to anger transforming into heat that disturbs the mind

● excessive thinking consumes yin-blood, which fails to nourish the heart Generally, mind disturbance is classified into patterns of deficiency and excess. Excess patterns are marked by fright, mania, irascibility, vexation, and agitation. Medicinals that calm the mind with heavy sedation are

applied. Palpitations, forgetfulness, restlessness, and insomnia characterize deficiency patterns. Medicinals that nourish the heart and calm the mind are applied. Therefore, the formulas in this chapter have the therapeutic actions to either calm the mind with heavy sedatives or to nourish the heart and calm the mind. In addition, complex patterns of deficiency and excess often exist because excessive heat consumes yin; and deficiency of yin may lead to excessive yang. Both can develop into mind disturbance patterns. As a result, formulas in this chapter are combinations of medicinals from the two categories in order to suit complex patterns. The formulas to calm the mind with heavy sedatives are often composed of medicinal metals, stones and shells. They easily impair the stomach qi, so it is inadvisable to take them for long. For those with deficiency of the stomach and spleen, medicinals that strengthen the spleen and harmonize the stomach should be added. Additionally, one should pay attention to toxic medicinals such as zhū shā because long-term ingestion can cause chronic poisoning.

Section 1 Mind-Calming Formulas with Heavy Sedatives Formulas to calm the mind with heavy sedatives are applicable to patterns of heart and liver yang hyperactivity and excessive heat disturbing the mind. They manifest vexation, insomnia, profuse dreaming, (severe) palpitations, epilepsy, and so on. Commonly used medicinals include zhū shā, cí shí, zhēn zhū mŭ, and lóng chĭ. When excessive heat disturbs the mind, one should add medicinals, such as huáng lián and shān zhī, that clear heat and drain fire. Pathogenic heat and fire consume yinblood, therefore,

one should also add medicinals that enrich yin and nourish blood such as shēng dì and dāng guī. The common representative formula is Zhū Shā Ān Shén Wán.

Zhū Shā Ān Shén Wán 朱砂安神丸Cinnabar Mind-Calming Pill Source Text Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn, 内外伤辨惑论)

Formula Ingredients

Preparation and Administration Grind the ingredients into powder and shape into pills with honey. One dose is approximately 6–9 g taken with warm water before sleep. It can also be prepared as a decoction.

Formula Indications Zhū Shā Ān Shén Wán is indicated for insufficient yin-blood caused by the hyperactivity of heart fire. The symptoms are insomnia, profuse

dreaming, (severe) palpitations, restlessness, and vexation. The tongue tip is red, and the pulse is thin and rapid.

Analysis of Fundamental Pattern Pathogenesis This formula is applied to patterns of hyperactive heart fire consuming yin-blood. The mind is disturbed by hyperactivity of the heart fire; while, the heart spirit is not nourished because of deficiency of yin-blood. So the symptoms of insomnia, profuse dreaming, palpitations, and vexation occur. The red tongue and thin, rapid pulse are signs of hyperactivity of heart fire and deficiency of yin-blood. The therapeutic method is to reduce excessive heat and enrich yin-blood to calm the mind.

Formula Actions Tranquilizes the heart and calms the mind, clears heat and nourishes the blood.

Formula Analysis

Unique Combination Features This combination not only drains heart fire, calms the heart, and tranquilizes the mind with heavy sedatives, it also enriches and nourishes heart yin, as well as supplement the heart blood, by treating the root and branch simultaneously. There is a nourishing action in the clearing. When the heart fire is cleared, yin-blood can be supplemented. As a result, the heart spirit is calmed. Symptoms are then automatically eliminated.

Formula Applications 1. Essential pattern differentiation Zhū Shā Ān Shén Wán is a common formula used to treat mind disturbance due to hyperactivity of the heart fire consuming yin-blood. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of hyperactivity of heart fire consuming yin-blood: insomnia, palpitations, forgetfulness, unclear mind due to melancholia, and palpitations caused by premature heart beating. 4. Cautions and contraindications This formula should not be taken either too much or too long because zhū shā contains mercuric sulfide, which can lead to mercury poisoning. It should be used with caution in those with yin deficiency and spleen weakness.

Associated Formulas Cí Zhū Wán (Loadstones and Cinnabar Pill, 磁朱丸), original name: Shén Qū Wán (Medicated Leaven Pill, 神曲丸) [Source] Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng, 备急千⾦要⽅) [Ingredients]

[Preparation and Administration] Grind the medicinal into powder, add honey, and make them into pills the size of phoenix tree seed. Take three pills (12 g) 1-2 times per day. [Actions] Boosts yin and improves vision, calms the mind with heavy sedatives. [Applicable Patterns] Non-interaction between the heart and the kidney. Symptoms include: tinnitus and deafness, palpitations, insomnia, blurred vision, and epilepsy. Zhū Shā Ān Shén Wán and Cí Zhū Wán both contain zhū shā to calm the mind with heavy sedation and can be used to treat insomnia, palpitations, profuse dreaming, and so on. Zhū Shā Ān Shén Wán combines huáng lián to drain heat with shēng dì and dāng guī to supplement yin-blood. It is good at clearing the heart and draining fire, enriching yin and nourishing blood to treat insomnia and palpitations due to hyperactivity of the heart fire consuming yin-blood. Cí Zhū Wán combines cí shí to boost yin and subdue yang. It is good at subduing yang, improving vision, and restoring the interaction between the heart and the kidney to treat insomnia, palpitations, tinnitus and deafness, and blurred vision due to deficiency of the kidney yin and hyperactivity of the heart yang, leading to non-interaction between the heart and the kidney.

Case Studies Palpitations

Hua Bo-ren treated a patient who had symptoms of palpitations, forgetfulness, salivation, dry tongue, profuse sweating, weak and sluggish limbs, fever, and white, turbid urine. Many doctors considered her pattern one of internal damage and deficiency and lù róng and fù zĭ were commonly prescribed. Her pulse was deficient, big, and rapid (rapid pulse indicates fire.) The doctor thought it was caused by excessive thinking, which resulted in jueyin fire. Bŭ Zhōng Yì Qì Tāng and Zhū Shā Ān Shén Wán were prescribed, as well as Xiăo Kăn Lí Wán (Minor Kăn Lí Pill, ⼩坎离丸), on an empty stomach. The patient recovered after taking the formulas for one month. 1 1 Jiang Guan. Classified Case Records of Famous Physicians. Vol. 8 名医类案·卷八. Beijing: China Press of Traditional Chinese Medicine; 1996. p. 173.

Comments: Normally monarchal fire and ministerial fire exist in harmony; the latter working for the former. When ministerial fire overworks, and replaces monarchal fire, diseases will occur that are associated with the heart. Qin Yue-ren said: grief, sadness, and excessive thinking can damage the heart. If one was over-ambitious about something, yet failed when attempting it, long-term depression may cause internal damage. Zhū Shā Ān Shén Wán and Xiăo Kăn Lí Wán clear heart fire and calm the mind. Bŭ Zhōng Yì Qì Tāng treats the internal damage, which is how the patient was cured.

Zhēn Zhū Mŭ Wán 珍珠母丸Concha Margaritiferae Usta Pill a.k.a. Zhēn Zhū Wán (真 珠丸) Source Text Experiential Formulas for Universal Relief (Pŭ Jì Bĕn Shì Fāng, 普济 本事⽅) Alias: Zhēn Zhū Mŭ Wán (Essentials of Infant Care, Vol. 10, Băo Yīng Cuō Yào, 保婴撮要), Zhēn Zhū Dān (Teachings of [Zhu] Dan-xi, Vol. 10, Dān Xī Xīn Fă, 丹溪⼼法).

Formula Ingredients

Preparation and Administration

Grind the ingredients into a fine powder and shape into pills using shén qū powder and zhū shā as a coating. One dose is approximately 6 g, taken with warm water three times daily.

Formula Indications Zhēn Zhū Mŭ Wán is indicated for hyperactivity of the heart and liver and deficiency of yinblood. Symptoms include palpitations, insomnia, and dizziness. The pulse is thin and wiry.

Analysis of Fundamental Pattern Pathogenesis This formula is applied to patterns caused by the heart failing to store the spirit due to deficiency of yin-blood and hyperactivity of the heart and liver. As yin and yang share a relation of mutual restriction and mutual waning and waxing, deficiency of yin leads to non-restriction of yang. The hyperactivity of the heart and liver results in dizziness as it rises to disturb the head. The result is restlessness, palpitations, and insomnia due to the heart failing to store the spirit. The pulse is thin and wiry, which indicates hyperactivity of the yang and yin deficiency of the heart and liver. The therapeutic method is to tranquilize the heart and calm the mind, calm the liver and subdue yang, and enrich yin and nourish blood.

Formula Actions Tranquilizes the heart and calms the mind, calms the liver and subdues yang, enriches yin and nourishes blood.

Formula Analysis

Unique Combination Features This formula combines medicinals that tranquilize the heart, calm the liver, enrich yin, nourish blood, and calm the mind. The combination of zhēn zhū mŭ, xī jiăo, lóng chĭ, and chén xiāng treats the branch by tranquilizing the heart and calming the mind and calming the liver and subduing yang.

Meanwhile, rén shēn, dāng guī, and shú dì huáng treating the root by nourishing blood and enriching yin, boosting qi and engendering blood. Therefore this formula treats the root and branch simultaneously. When yin is enriched and yang is subdued, and the relationship between the heart and liver is rebalanced, the symptoms are relieved.

Formula Applications 1. Essential pattern differentiation Zhēn Zhū Mŭ Wán is an effective formula used to treat fright, palpitations, and insomnia caused by deficiency of yin-blood and hyperactivity of the heart and liver. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of neurasthenia due to deficiency of yin-blood and hyperactivity of the heart and liver: insomnia, palpitations, epilepsy, and emotional depression. 4. Cautions and contraindications

This formula should be cautiously applied in those with phlegm-damp or phlegm-heat because it contains greasy and astringent medicinals such as shú dì huáng and suān zăo rén, which may retain the pathogens.

Comparison & Contrast Zhū Shā Ān Shén Wán vs. Zhēn Zhū Mŭ Wán

Section 2 Enriching and Nourishing Formulas that Calm the Mind Enriching and nourishing formulas that calm the mind are applicable to patterns of yinblood deficiency failing to nourish the heart and mind. The signs and symptoms include vexation, insomnia, palpitations, forgetfulness, and profuse dreaming. The tongue is red with scanty coating. Commonly used medicinals that enrich and calm the mind are suān zăo rén, băi zĭ rén, wŭ wèi zĭ, fú shén, yuăn zhì, and xiăo mài. Medicinals that enrich yin and nourish blood, such as shēng dì, dāng guī, mài dōng, and xuán shēn, are usually used in combination with those that enrich and calm the mind. Common formulas are Tiān Wáng Bŭ Xīn Dān and Suān Zăo Rén Tāng.

Tiān Wáng Bŭ Xīn Dān 天王补⼼丹Celestial Emperor Heart-Supplementing Elixir Source Text Corrections and Annotations to Fine Formulas for Women (Jiào Zhù Fù Rén Liáng Fāng, 校注妇⼈良⽅)

Formula Indications

Preparation and Administration Grind the ingredients into a fine powder and shape into pills using honey and coat the pills with 5–15 g of zhū shā that has been ground with water. One dose is approximately 6–10 g taken with warm water or with a longan decoction. It can also be prepared as a decoction.

Formula Indications Deficiency of yin and insufficiency of blood have lead to the disturbance of the mind. Symptoms include palpitations, vexation, insomnia, mental fatigue, forgetfulness, nocturnal emission, feverish feeling in palms and soles, aphtha, a sore mouth and tongue, and dry stool. The tongue is red with scanty coating, and the pulse is thin and rapid.

Analysis of Fundamental Pattern Pathogenesis

This pattern is caused by excessive heart fire consuming yin-blood. Excessive heart fire disturbs the heart spirit, while insufficiency of yin-blood leads to a lack of nourishment of the heart spirit. The pattern is manifest by insomnia, profuse dreaming, palpitations, and vexation. The red tongue and thin and rapid pulse also indicates that the pathomechanism is excessive heart fire and deficiency of yinblood. The therapeutic method is to drain excessive fire and supplement yin-blood to calm the mind.

Formula Actions Enriches yin and clears heat, nourishes blood and calms the mind.

Formula Analysis

Unique Combination Features Simultaneously treating the root, by enriching yin and supplementing blood, and treating the branch, by nourishing the heart to calm the mind, characterize it. In other words, while it predominantly supplements the heart to treat the root, it treats the heart and the kidney simultaneously. The therapeutic action of the formula is to enrich yin, nourish blood, supplement the heart, and calm the mind.

Formula Applications

1. Essential pattern differentiation Tiān Wáng Bŭ Xīn Dān is applicable to patterns of heart and kidney deficiency, deficiency of yin, shortage of blood, and deficiency-fire disturbing the interior mainly caused by excessive grief and thinking that consumes yin-blood. Deficiency of yin and shortage of blood fail to nourish the heart. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency of yin and blood of the heart and kidney: insomnia, palpitations, recurrent oral ulcer due to neurasthenia, coronary heart disease, schizophrenia, and hyperthyroidism. 4. Cautions and contraindications This formula should be cautiously applied to patients who have spleen and stomach deficiency marked by long-term poor appetite and loose stool because it contains many medicinals that enrich yin.

Associated Formulae Băi Zĭ Yăng Xīn Wán (Platycladi Heart-Nourishing Pill, 柏⼦养⼼丸) [Source] A Compilation of Benevolent Formulas (Tĭ Rén Huì Biān, 体仁汇编) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills with the size of a phoenix tree seed using honey. 40-50 pills (9 g) are taken as one dose. [Actions] Nourishes the heart, calms the mind, enriches yin, and supplements the kidney. [Applicable Patterns] Deficiency of yin-blood and disharmony of the heart and kidney. Symptoms include: unclear mind, palpitations, profuse dreaming, forgetfulness, night sweat, a red tongue and scanty coating, and a thin, rapid pulse. Kŏng Shèng Zhěn Zhōng Dān (Confucius Pillow Elixir, 孔圣枕中丹) [Source]

Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng, 备急千⾦要⽅) [Ingredients] guī jiă, lóng gŭ, shí chāng pú, yuăn zhì all in equal dosage rations, taken 3 g at once. [Actions] Supplements the kidney, calms the heart, improves intelligence, and calms the mind. [Applicable Patterns] Yin deficiency of the heart and kidney. Symptoms include: insomnia, forgetfulness, unstable mood, dizziness, a red tongue, a thin, white coating, and a thin, wiry pulse. Tiān Wáng Bŭ Xīn Dān, Băi Zĭ Yăng Xīn Wán, and Kŏng Shèng Zhěn Zhōng Dān are formulas used to treat vexation and insomnia due to the deficiency of yin-blood. Tiān Wáng Bŭ Xīn Dān combines yin-enriching and blood-nourishing medicinals with heart-supplementing and mindcalming ones. It has a powerful action to enrich yin and clear heat because the dose of shēng dì is increased significantly, and it contains tiān mén dōng, mài mén dōng, and xuán shēn. Tiān Wáng Bŭ Xīn Dān is used for deficiency of yin with internal heat and disturbance of the mind. Băi Zĭ Yăng Xīn Wán combines kidney-supplementing and yin-enriching medicinals with heartnourishing and mindcalming medicinals. In it, băi zĭ rén and gŏu qĭ zĭ are used heavily. It moderately enriches yin and clears heat, and is used to treat deficiency of the heart and kidney with mild internal heat.

Kŏng Shèng Zhěn Zhōng Dān combines guī jiă and lóng gŭ to enrich yin, subdue yang, calm the mind, and improve intelligence with shí chāng pú and yuăn zhì in order to restore healthy interaction between the heart and the kidney. Kŏng Shèng Zhěn Zhōng Dān is used to treat yin deficiency of the heart and kidney and hyperactivity of the heart yang, marked by forgetfulness and insomnia.

Case Studies Palpitations The patient’s palpitations started when he had an experience of fright and fear. After the incident, he continued to have them but had gotten used to having them. The palpitations were accompanied with trembling hands and intolerance to labor. His tongue was dry. His pulse was hollow and slippery. It was a pattern of heart-blood deficiency and phlegm accumulation. He was prescribed: rén shēn, xuán shēn, dān shēn, suān zăo rén, tiān mén dōng, mài dōng, shí chāng pú, fú líng, fú shén, dāng guī, yuăn zhì, wŭ wèi zĭ, jié gĕng, bàn xià, shēng dì, jú hóng, zhĭ qiào, băi zĭ rén, zhì gān căo, and zhú rú.1 Comments: This formula composed of a combination of Tiān Wáng Bŭ Xīn Dān and Shí Wèi Wēn Dăn Tāng. Tiān Wáng Bŭ Xīn Dān was prescribed to treat the heart-blood deficiency and Shí Wèi Wēn Dăn Tāng was prescribed to treat the phlegm accumulation. 1 Liu Bao-yi. Liu’s Selected Case Records of Four Physicians 柳选四家医案·评选继志堂医案. Beijing: China Press of Traditional Chinese Medicine; 1997. p. 80-81.

Suān Zăo Rén Tāng 酸枣仁汤Sour Jujube Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Prepare as a decoction, consume while it is warm.

Formula Indications Suān Zăo Rén Tāng is indicated for deficiency of liver-blood with internal deficiency heat. The symptoms are vexation, insomnia, palpitations, restlessness, dizziness, dry throat, dry mouth, a red tongue, and a wiry, thin pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by excessive heart fire consuming yin-blood. Excessive fire of the heart disturbs the heart and spirit. Meanwhile,

deficiency of yin-blood fails to nourish the heart and spirit manifesting insomnia, profuse dreaming, palpitations, and vexation. A red tongue and rapid, thin pulse are signs of excessive heart fire and deficiency of yin-blood. The therapeutic principle is to reduce excessive fire and supplement yinblood to calm the mind.

Formula Actions Nourishes blood and calms the mind, clears heat and relieves vexation.

Formula Analysis

Continued

Unique Combination Features This formula is characterized by treating the root and branch simultaneously. It clears while nourishing, and moves while supplementing. It has therapeutic actions to nourish blood, calm the mind, clear heat, and relieve vexation.

Formula Applications 1. Essential pattern differentiation Suān Zăo Rén Tāng serves as a common formula used in patterns of vexation and insomnia due to blood deficiency of the heart and liver. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of blood deficiency of the heart and liver with internal deficiency: neurasthenia, heart neurosis, and menopausal syndrome.

Associated Formulae Gān Mài Dà Zăo Tāng (Licorice, Wheat and Jujube Decoction, ⽢麦 ⼤枣汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

[Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Nourishes the heart and calms the mind, harmonizes the center and relieves spasms. [Applicable Patterns] Zàng zào (脏躁). Symptoms include: an unclear mind, uncontrolled feelings of sadness and crying, restlessness, feeling upset during sleep, strange words and behavior, frequent yawning, a pale tongue with scanty coating, and a thin, rapid pulse.

Comparison & Contrast Suān Zăo Rén Tāng vs. Tiān Wáng Bŭ Xīn Dān

Case Studies Insomnia A 32-year-old female had been suffering from insomnia since the winter of 1936. She has tried many kinds of medicines that did not work. Her symptoms included emaciation, lack of qi and spirit, vexation, insomnia, profuse dreaming, unstable spirit as if losing something, dizziness, poor appetite, red cheeks, a crimson tongue, and a wiry, thin pulse. She had a pattern of yin deficiency and insufficiency of ying-blood. Insufficiency of ying failed to nourish the heart, and insufficiency of blood failed to nourish the liver. Her spirit was unable to be controlled because of the deficiency of the heart and the soul, and was unable to be stored because of the deficiency of the liver. Furthermore, hyperactivity of yang due to yin deficiency would ascend to disturb the mind. The therapeutic method was to nourish the heart

and calm the mind. She was prescribed Suān Zăo Rén Tāng with rén shēn, zhēn zhū mŭ, băi hé, bái sháo, and yè jiāo téng added. The formula was prepared as a decoction for oral ingestion. In addition, lăo hŭ mù jīng was ground into powder and taken with water. After taking thirteen doses, she could fall asleep as her spirit was able to be stored, and all of her symptoms were relieved. 1 1 Lai Liang-pu. Pu Yuan’s Medical Cases 蒲园医案. Nanchang: Jiangxi People’s Publishing House; 1965. p. 38.

Comments: The patient had the typical manifestations of vexation and insomnia due to insufficiency of the ying-blood and disturbance caused by internal heat. Therefore, Suān Zăo Rén Tāng with zhēn zhū mŭ was applied to subdue yang and calm the ethereal soul. Lăo hŭ mù jīng was applied to calm the corporeal as its nature is motionless. Băi hé blossoms at sunrise and closes at sunset, so it helped her to adapt to the alternation of day and night. Yè jiāo téng intercrossed the right and left to improve the communication of yin and yang. Bái sháo subdued liver yang. When wood was even and fire descended, the mind and soul were in peace, and her insomnia was relieved.

Summary There are four fundamental and two associated formulas within the mind-calming formulas chapter. According to their actions, they were classified into two categories:

● mind-calming formulas with heavy sedatives ● enriching and nourishing formulas that calm the mind 1. Mind-calming formulas with heavy sedatives Zhū Shā Ān Shén Wán tranquilizes the heart and calms the mind, clears heat and nourishes the blood. It is indicated for insufficient yin-blood caused

by the hyperactivity of heart fire. Zhēn Zhū Mŭ Wán tranquilizes the heart and calms the mind, calms the liver and subdues yang, enriches yin and nourishes blood. It is indicated for hyperactivity of the heart and liver and deficiency of yin-blood. 2. Enriching and nourishing formulas that calm the mind Both Tiān Wáng Bŭ Xīn Dān and Suān Zăo Rén Tāng nourish the heart and calm the mind, enrich yin and supplement the blood, and are designed for palpitations, vexation and insomnia due to deficiency of yin and insufficiency of blood leading to the disturbance of the mind. Tiān Wáng Bŭ Xīn Dān is perfect for the pattern of heart-kidney yin and blood insufficiency. Suān Zăo Rén Tāng is appropriate for the pattern of liver blood insufficiency.

Questions 1.What are the indications for mind-calming formulas with heavy sedatives and enriching and nourishing formulas that calm the mind, respectively? What are the differences in compatibility between them? What are the relations among them? 2.What are special combination features of mind-calming formulas with heavy sedatives? What should one be aware of during their administration?

CHAPTER 10 Qi-Rectifying Formulas Qi-rectifying formulas are composed of qi-rectifying medicinals. They have the functions to move qi or direct qi downward in order to treat qi stagnation or qi counterflow. They are categorized as the “dispersion method” according to the Eight Treatment Methods. Qi dominates the functional activities of the whole body by way of descending, ascending, entering, and exiting interiorly within the zang-fu organs and exteriorly at the muscles and pores. Its circulation reaches the whole body and maintains its normal physiological activities. Emotional disorders, overstrain, improper diet, and abnormal weather changes can all result in dysfunction of the zang-fu, as well as, disorders of the ascending and descending of qi that lead to multiple diseases. The four types of qi diseases include qi deficiency, qi sinking, qi stagnation, and qi counterflow. The treatment principles and formulas for the patterns of qi deficiency and qi sinking are introduced in Chapter 7 Supplementing and Boosting Formulas. This chapter will discuss the treatment principles and formulas for the patterns of qi stagnation and qi counterflow. Formulas that treat qi stagnation address liver qi binding constraint and spleen-stomach qi stagnation by moving qi. Formulas that treat qi counterflow address ascending counterflow of lung and stomach qi by directing qi downward. Therefore, the formulas in this chapter are divided into two sections:

● qi-moving formulas

● qi-descending formulas First, it is important to differentiate qi disorders before prescribing qirectifying formulas. The rules of excess and deficiency should not be overlooked. If the case is an excess pattern of qi stagnation, the qi-moving method should be applied to resolve it. The qi should not be supplemented by mistake. However if the case is a qi deficiency pattern, moving qi by mistake may further deplete qi. Second, combined patterns need to be considered. If qi stagnation and counterflow qi coexist, the methods of moving qi and directing qi downward are combined. Combinations are formulated according to the priorities of each pattern involved. As an example, if a qi stagnation pattern is combined with qi deficiency, an appropriate amount of qi supplementing medicinals can be added to the prescription. Third, most of the qi-rectifying medicinals are aromatic, acrid, and dry in property, which may injure fluid and qi. These formulas should not be overused; especially for elderly patients, or those with a weak body constitution, yin deficiency with vigorous fire, pregnancy, metrorrhagia, metrostaxis, bleeding nose, or those expectorating blood.

Section 1 Qi-Moving Formulas Qi-moving formulas are used to treat qi stagnation patterns. Qi stagnation commonly manifests as spleen-stomach qi stagnation and liver qi binding constraint. The signs and symptoms of stomach qi stagnation include epigastric and abdominal pain and distention, belching, acid swallowing, nausea and vomiting, poor appetite, and bowel disorders. Common medicinals used to rectify stomach qi are chén pí, hòu pò, zhĭ qiào, mù xiāng, and shā rén. The signs and symptoms of liver qi stagnation

include chest and hypochondriac distention pain, shàn qì pain, menstrual irregularities, and painful menstruation. Common medicinals used to soothe the liver qi are xiāng fù, qīng pí, yù jīn, chuān liàn zĭ, wū yào, and xiăo huí xiāng. Common formulas in this category are Yuè Jú Wán, Chái Hú Shū Gān Săn, Jīn Líng Zĭ Săn, Zhĭ Shí Xiè Bái Guì Zhī Tāng, Bàn Xià Hòu Pò Tāng, Tiān Tái Wū Yào Săn, Jú Hé Wán, Nuăn Gān Jiān, and Jiā Wèi Wū Yào Tāng.

Yuè Jú Wán 越鞠丸Constraint-Resolving Pill a.k.a. Xiōng Zhú Wán (Chuanxiong and Atractylodes Pill, 芎术丸) Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

Preparation and Administration Grind all of the ingredients into powder. Form the powder into pills the size of a mung bean using water. (Modern use: Process into water pills. One dose is approximately 6-9 g, taken with warm water. It can also be prepared as a decoction.)

Formula Indications Yuè Jú Wán is indicated for the pattern of six constraints. The symptoms are chest oppression, epigastric and abdominal distention or pain, eructation with fetid odor, acid swallowing, nausea, vomiting, and indigestion.

Analysis of Fundamental Pattern Pathogenesis Yuè Jú Wán treats the pattern of six constraints: qi constraint, blood constraint, phlegm constraint, fire constraint, damp constraint, and food constraint. Of these, qi constraint is the major pathomechanism as qi is the root of human life. When qi movement is balanced and its perpetual circulation of ascending, descending, exiting, and entering is in order, the zang-fu organ functions can be regulated and the extremities and joints soothed. Irregular bouts of happiness and anger, excessive worry, being too hot or too cold, or an imbalanced diet can cause a qi movement disorder to develop into a disease. Qi stagnation can hinder blood circulation and lead to blood constraint. When qi stagnation affects the body fluid distribution, it leads to damp and phlegm constraint. When it affects the transformation and transportation of the spleen and the receiving of the stomach, it leads to food constraint. If qi constraint is not resolved, it will generate heat and transform into fire. All of the constraints follow qi constraint. Here, the six constraints are already established, so there is chest oppression, epigastric and abdominal pain and distention, acid swallowing, vomiting, and indigestion. Qi constraint is the primary pattern of this formula, yet qi constraint, blood constraint, fire constraint, damp constraint, phlegm constraint, and food stagnation are all related with each other. The primary therapeutic principle

is to move qi and resolve constraint. Resolving the other constraints is secondary. The smooth flow of qi promotes blood circulation and resolves phlegm, fire, damp, and food constraint simultaneously.

Formula Actions Moves qi and resolves constraint.

Formula Actions

Unique Combination Features First, this formula treats all six constraints; however, its focus is on resolving qi stagnation and regulating qi movement. Second, five medicinals are used to treat the six constraints without directly addressing the phlegm constraint because phlegm constraint is generated from qi stagnation, dampness accumulation, food stagnation, and fire concentrating the body fluid. Qi-moving, dampness-resolving, food-eliminating, and fire-clearing medicinals are all contained in the formula. When all five constraints have been resolved, phlegm constraint is eliminated automatically. This is an illustration of the principle to treat the root of a disease pattern.

Formula Applications 1. Essential pattern differentiation Yuè Jú Wán is the representative formula used to treat six constraints. This clinical pattern is marked by:

● chest oppression ● epigastric and abdominal pain and distention ● indigestion 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of the six constraints pattern: gastric neurosis, gastric and duodenal ulcers, chronic gastritis, cholelithiasis, cholecystitis, hepatitis, intercostal neuralgia, women’s dysmenorrhea, and irregular menstruation.

4. Cautions and contraindications Most of the medicinals in this formula are warm and dry with the action to move and disperse; therefore, it should be used cautiously in cases of yin deficiency.

Case Studies 1. Depressive psychosis Ms. Zhao, 51 years old, had her initial visit on September 21st, 1988. The patient presented with spontaneous sweating, aversion to wind and cold, vexation, gasping for breath, insomnia, profuse dreaming, and depression during the recent six months. She never smiled during these six months. She was flustered and suffered epigastric discomfort, no desire to eat, dry mouth, dry stool, vexing heat in the five centers, a thin, white coating, and a wiry pulse. The pattern was diagnosed as abnormal qi movement and yin-yang disharmony. The therapeutic methods were to move qi and resolve constraint, nourish the heart and calm the mind, harmonize the center, and moderate spasm. Six doses of Yuè Jú Wán combined with Gān Mài Dà Zăo Tāng (Licorice, Wheat and Jujube Decoction, ⽢麦⼤枣汤) with modifications were prescribed, composed of the following ingredients: cāng zhú 10 g, chuān xiōng 10 g, xiāng fù 10 g, zhī zĭ 10 g, shén qū 10 g, gān căo 5 g, dà zăo 5 pieces, fú xiăo mài 15 g, lóng gŭ 15 g, dàn dòu chĭ 10 g, dì gŭ pí 10 g, zhēn zhū mŭ 15 g, and yè jiāo téng 15 g. After one week, the symptoms improved; however, the tongue and pulse did not change. Six more doses of the same formula were then prescribed for three weeks with good effect. The patient herself mentioned that she could chat with family members, her sweating had been controlled, appetite improved, and sleep was more stable than before. Six more doses were prescribed to strengthen the effect.1

Comments: This type of patient is often diagnosed with depressive psychosis by Western medicine. However, according to traditional Chinese medicine, they suffer a pattern of yù (constraint, 郁) or zàng zào (visceral agitation, 脏躁). Sometimes these cases are treated by nourishing yin and clearing heat, but the effect is not always satisfactory. Master Gao suggests that this pattern should not always be differentiated as yin deficiency as qi constraint patterns are more common. This disease is caused by irregularity of the heart and the liver, so Yuè Jú Wán in combination with Gān Mài Dà Zăo Tāng matches the pathogenesis. It is said in the Golden Mirror of the Medical Tradition that human beings are rooted in qi and disease would never occur if qi is regulated within its limits and circulates properly. An improper diet, being too hot or too cold, irregular amounts of happiness or anger, and worrying too much can lead to irregular ascending and descending of qi. As a result, poor appetite due to stomach constraint, indigestion of food and water due to spleen constraint, and qi movement disorders due to blood and qi constraint are generated. When there is disharmony of yin and yang, insomnia results. Fire constraint generates heat syndromes. Yuè Jú Wán combined with Gān Mài Dà Zăo Tāng with additional heat-clearing and mind-calming medicinals can resolve the six constraints, nourish and supplement with sweet moderate properties, soften the liver, relieve spasm, relax the heart, and calm the mind. Thereby, yingwei was harmonized, qi and blood regulated, and yin and yang balanced curing the disease. 2. Menstrual headache 1 Dong Jian-hua, Wang Yong-yan. Elite Medical Cases of Famous Modern TCM Doctors. Vol. 6 中国现代名中医医案精华六. Beijing: Beijing Publishing House; 2002. p. 417.

Ms. Zhou, 34 years old, suffered from severe menstrual headaches for about three years. The headache starts at the 2nd or 3rd day before every

period and worsens day by day until the 1st day of her menstrual period. At its extreme, it feeled like her head is going to explode. She always needed an injection of analgesics or sedatives to relieve the pain. The headache would then reduce starting from the 2nd day of her period and vanish once her period ends. At the onset of the headache, she also suffered with dizziness, nausea, aversion to food, soreness of the low back and extremities, and painful distension of the lower abdomen. Her menstrual cycle was generally unhealthy with dark blood clots. she had a red tongue body, stasis macules on the margins of the tongue, a slight yellow coating, and a thin, wiry pulse. The pattern was diagnosed as internal obstruction of static blood with liver fire flaming upward. The treatment methods selected were to clear heat, calm the liver, invigorate blood, and dissolve stasis. She was prescribed xiāng fù (prepared) 10 g, cāng zhú (prepared) 10 g, hēi shān zhī 10 g, táo rén 10 g, bái zhĭ 10 g, jiāo shén qū 10 g, jú huā 15 g, niú xī 15 g, shí jué míng 15 g, shēng gān căo 5 g, and chuān xiōng 6 g. The decoction was to be taken five days before the onset of the menstrual period, one dose each day. The headache did not manifest when her next menstruation period came, but there was still distending pain in the lower abdomen. Jú huā and bái zhĭ were removed from the former prescription and wū yào 10 g and guăng mù xiāng 10 g were added. After taking five more doses, all of the above symptoms were alleviated and never recurred.1 Comments: Menstrual headaches are typically caused by liver constraint and qi stagnation, internal obstruction of static blood, phlegmdamp obstruction, or malnourishment of the clear orifices. Long-term constraint can transform into fire. Liver fire, together with qi of the chong channel, counterflows before the menstrual period starts, which disturbs the clear orifices and leads to severe menstrual headache and dizziness. Modified Yuè Jú Wán can soothe constraint in the liver channel, invigorate

blood, dissolve stasis, regulate menstruation, nourish blood, clear heat, and calm the liver. As a result, blood stasis and damp-heat were eliminated, the collaterals soothed, menstruation flow unobstructed, and the chong channel qi undisturbed. Thereby, the disease was cured.

Chái Hú Shū Gān Săn 柴胡疏肝散Bupleurum Liver-Soothing Powder Source Text System Compiled Medical Works (Yī Xué Tŏng Zhĭ, 医学统旨) recorded by Standards for Diagnosis and Treatment (Zhèng Zhì Zhŭn Shéng, 证治准绳)

Formula Ingredients

Preparation and Administration Prepare as a decoction. 1 Li Bo-tang. Li Peng-lin’s Application of Yuè Jú Wán for Gynecological Diseases 李鹏林运⽤ 越鞠丸治疗妇科病验案举隅. Zhejiang Journal of Traditional Chinese Medicine. 1997: (9): 389.

Formula Indications Chái Hú Shū Gān Săn is indicated for patterns of liver qi stagnation. The symptoms are ribside pain, chest oppression, tendency to sigh,

depression and irritability, belching, and epigastric and abdominal distention. The pulse is wiry.

Analysis of Fundamental Pattern Pathogenesis The liver governs the free flow of qi and its qi prefers to be uninhibited. Its channels distribute over the areas of the ribs. When the liver qi stagnates due to emotional disorders and dysfunction of the liver’s distribution, ribside pain, chest oppression, tendency to sigh, depression, and irritability result. Long term liver stagnation can transversely invade the stomach to cause stomach qi disharmony which manifests as frequent belching and epigastric and abdominal distention. A wiry pulse indicates liver qi stagnation. The therapeutic principle is to soothe the liver, resolve constraint, and move qi to relieve pain.

Formula Actions Soothes the liver and resolves constraint, moves qi to relieve pain.

Formula Analysis

Unique Combination Features This formula soothes the liver by softening it, moving the qi while harmonizing the blood, and by treating the liver and harmonizing the stomach simultaneously. It is a fine formula to soothe the liver, resolve constraint, move qi, and relieve pain.

Formula Applications 1. Essential pattern differentiation Chái Hú Shū Gān Săn is commonly indicated for patterns characterized by liver qi stagnation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver qi stagnation such as chronic hepatitis, cholecystitis, bile reflux gastritis, intercostal neuralgia, dysmenorrhea, irregular menstruation, premenstrual tension syndrome, breast hyperplasia, chloasma, and sexual dysfunction. 4. Cautions and contraindications This is an aromatic, dry formula that can consume qi and yin. Therefore, long-term usage is not recommended. Use with caution in pregnant women.

Case Studies 1. Tuí shàn (testicular hardness and swelling pain, 颓疝) Mr. Lai, a 25-year-old Ping Xiang county citizen. In the late autumn of 1953, the patient had a swollen right testicle the size of a duck egg, hard in texture, and was in unbearable pain. The patient had a feeling of upward

surging qi from lower abdomen attacking yāo yǎn (EX-B7 point). It caused distending rib-side pain and was accompanied by a vertex headache and vomiting saliva. The pulse was wiry and tight, and the coating was thin and white. It was concluded that he had cold-dampness accumulating into the blood collaterals and jueyin channel. It was a syndrome of collateral deficiency with qi accumulation. The appropriate treatment was to soothe the liver and rectify qi. Modified Chái Hú Shū Gān Săn was prescribed, composed of chái hú 6 g, bái sháo 9 g, qīng pí 6 g, chuān xiōng 5 g, xiāng fù 9 g, chuān liàn zĭ 9 g, xiăo huí xiāng 3 g, and guăng mù xiāng 3 g. His symptoms were alleviated after taking four doses of the decoction. He took several more doses of the formula with chuān xiōng removed and wū yào 9 g and jú hé 18 g added, and he completely recovered.1 1 Lai Liang-pu. Medical Cases of Pu’s Garden蒲园医案. Nanchang: Jiangxi People’s Publishing House; 1965. p. 166.

Comments: The Yellow Emperor’s Inner Classic noted that “the jueyin channel connects to the genital organs” [1] and that “ren mai disease is related to the seven shàn-hernia of male patients” [2]. Therefore, shàn-hernia syndrome is always related to the jueyin and ren mai channels. Colddampness lodged in the jueyin channel caused collateral deficiency and qi stagnation. The warming and soothing methods were undoubtedly the correct choices so Chái Hú Shū Gān Săn was applied. Zhĭ qiào eliminates qi stagnation in chest and abdomen. Chuān liàn zĭ and xiăo huí xiāng were added to soothe the liver and treat shàn-hernia. When the symptoms were alleviated, the formula was modified to soothe the liver, dissipate nodules, and treat shàn-hernia with jú hé. This completed the entire treatment. 2. Low- grade fever This patient had a common cold that started with a fever six months ago. It had not been treated by inducing sweating to release the exterior in

time. Instead, she took some fever reducing tablets and pills which quelled the fever. However a week later, the low-grade fever came back because of anger. Since then, she had chills before fever; her body temperature reached 37.2-37.6°C, and was treated for an unidentified fever for six months without a curative effect. Her pulse was wiry, a little bit thin and slightly rapid. The tongue was slightly red with a thin, white coating. Besides the lowgrade fever, she had scanty and delayed menstruation, dull pain on the rib-side, poor appetite, dry stool, and fatigue. The treatment was to harmonize shaoyang and soothe the liver by using Chái Hú Shū Gān Săn with chuān xiōng and chén pí removed and shēng dì 15 g, xuán shēn 12 g, qín jiāo 12 g, qīng hāo 20 g and dì gŭ pí 10 g added. She recovered after taking ten doses.1 Comments: This patient’s common cold seems to be cured, but getting angry induced the onset of low-grade fever, delayed menstruation, and hypochondriac dull pain. These symptoms indicate that the exterior pathogen was not entirely resolved, but entered the shaoyang and stayed there. The anger then caused liver qi stagnation. Her syndrome was caused by a combination of an old pathogen with new one. The treatment was to harmonize the shaoyang and soothe the liver by using Chái Hú Shū Gān Săn with chuān xiōng and chén pí removed and yin-nourishing and feverreducing medicinals added.

Jīn Líng Zĭ Săn ⾦铃⼦散Toosendan Powder Source Text Formulas from Benevolent Sages Compiled during the Taiping Era (Tài Píng Shèng Huì Fāng,太平圣惠⽅), recorded in Pocket Prescriptions (Xiù Zhēn Fāng, 袖珍⽅)

Formula Ingredients

Preparation and Administration Grind the ingredients into powder and take 6-9 g each dose with wine or warm water. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios. 1 Jiao Shu-de. Ten Lectures of Experience Gained in Formulas⽅剂⼼得⼗讲. Beijing: People’s Medical Publishing House; 1995. p. 94.

Formula Indications Jīn Líng Zĭ Săn is indicated for the pattern of liver constraint transforming into fire. The symptoms are pain of the chest, abdominal, and hypochondrium that suddenly occurs and ceases, bitter taste in the mouth, painful menstruation, and shàn qì-hernia pain. The tongue is red and the coating is yellow. The pulse is wiry and rapid.

Analysis of Fundamental Pattern Pathogenesis

The liver stores the blood and governs the free flow of qi. It prefers free flow. Its channel distributes into the rib-side region, reaches the lower abdomen, and connects with the genital organs. Liver qi stagnation leads to qi disorders and problems with blood circulation. Hence, pain of the chest, abdomen or hypochondrium suddenly occurs and ceases. The condition is worsened with emotional changes. As qi constraint transforms into fire, the symptoms include a bitter taste in the mouth. The tongue is red and the coating is yellow. The pulse is wiry and rapid. The therapeutic method is to soothe the liver qi, drain the liver fire, invigorate blood, and relieves pain.

Formula Actions Soothes the liver qi, drain the liver fire, invigorates blood and relieves pain.

Formula Analysis

Unique Combination Features The methods of qi-moving, blood-invigorating, constraint-resolving, and heat-draining are combined together. Thereby, qi and blood can be

soothed, liver heat be cleared, and all the pain be cured.

Formula Applications 1. Essential pattern differentiation Jīn Líng Zĭ Săn is commonly indicated for the pattern of chest, abdominal, and hypochondriac pain due to liver constraint transforming into fire. It is also the basic formula for treating all kinds of pain due to qi and blood stagnation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver fire transforming into fire: gastritis, cholecystitis, gastrointestinal spasm, intercostal neuralgia, and rib cartilage inflammation. 4. Cautions and contraindications It is inadvisable to use this formula alone for liver qi stagnation in a cold pattern.

Case Studies Epigastric pain Ms. Yin, a 60-year-old retired worker, had her initial visit on October 21st, 1982. The patient had epigastric pain for several months. She had taken about twenty doses of a formula that was prescribed to warm the center and supplement the spleen using sweet, warm medicinals. The pain become worse each day and was accompanied with a burning sensation, oppressive fullness in the abdomen, nausea, hiccup, poor appetite, bitter taste in the mouth, bad breath, and yellow urine. Her tongue was red with a yellow coating, and the pulse was wiry, rapid, and strong. Her pattern was differentiated as liver constraint transforming into fire transversely attacking the stomach. The therapeutic principle was to calm the liver, descend counterflow, and clear heat to relieve pain. Modified Jīn Líng Zĭ Săn was prescribed, composed of: chuān liàn zĭ 12 g, yán hú suŏ 9 g, dài zhĕ shí 9 g, mài dōng 9 g, zhī zĭ 6 g, qīng mù xiāng 6 g, and gān sōng 4.5 g. After taking six doses the patient still had dull pain in epigastrium; however, the nausea and hiccups improved and her appetite increased. She still had a bitter taste in the mouth, dry throat, and red lips with dry cracks. Her tongue was red and dry, and her pulse was wiry and rapid. This indicated liver fire had been slightly balanced, but the stomach yin was already damaged. The correct treatment was to calm the liver and harmonize the stomach, clear heat, and nourish yin. Modified Jīn Líng Zĭ Săn was prescribed, composed of: chuān liàn zĭ 9 g, yán hú suŏ 9 g, yù jīn 9 g, mài yá 9 g, bái sháo 12 g, shí hú 12 g, and gān căo 2 g. The symptoms were gone after five doses.1 1 Peng Shu-xian. Examples of Application of Jīn Líng Zĭ Săn Modification for Pain Syndrome⾦ 铃⼦散加味治疗痛证验案举隅. Forum on Traditional Chinese Medicine. 1988; (3): 41.

Comments: The liver channel connects with the stomach, belongs to the liver, and shares an interior/exterior relationship with the gallbladder. This

case was caused by an emotional disorder, liver failing to govern free flow, qi constraint transforming into fire, and a transverse attack to the stomach. Jīn Líng Zĭ Săn, with an addition of dài zhĕ shí, was prescribed to calm the liver and descend counterflow. Gān sōng and qīng mù xiāng were added to move qi and relieve pain and zhī zĭ and mài dōng were added to drain fire and nourish yin. After taking six doses the pain was relieved, but the stomach yin was already damaged. Therefore, Jīn Líng Zĭ Săn modified with additional yinnourishing and stomach-harmonizing medicinals were prescribed to cure this case.

Zhĭ Shí Xiè Bái Guì Zhī Tāng 枳实薤⽩桂枝汤 Immature Bitter Orange, Chinese Chive and Cinnamon Twig Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Decoct zhĭ shí and hòu pò in 5 sheng water and reduce to 2 sheng then filter the residue. Add the rest of the ingredients and bring it to a boil once again. Divide the decoction into three equal parts. It is to be taken warm three times per day. (Modern use: It can also be prepared as a decoction.)

Formula Indications Zhĭ Shí Xiè Bái Guì Zhī Tāng is indicated for chest bì caused by chest yang weakness, phlegm obstruction, and counterflow qi. The symptoms are fullness and pain in the chest, chest pain radiating to the back, panting, cough, spitting, shortness of breath, hypochondriac qi counterflowing

upward to heart and chest. The coating is white and greasy, and the pulse is deep, wiry or tight.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by chest yang weakness, fluid concentrated into phlegm, binding of qi and phlegm, and yin-cold qi counterflow. Phlegm is a yin pathogen which tends to obstruct the movement of qi. When it collects in the chest, fullness and pain in the chest results. The pain may radiate between the chest and the back. Phlegm obstruction along with lung failing to diffuse and govern descent leads to panting, cough, spitting, and shortness of breath. When the chest yang is weak, yincold qi counterflows and the patient can feel it rising from the hypochondria to attack the heart and chest. The root of this pattern is chest yang weakness, while the branches are phlegm obstruction and qi stagnation with counterflow qi. Therefore, the therapeutic methods are to unblock yang, dissipate masses, dispel phlegm, and lower qi.

Formula Actions Unblocks yang and dissipates masses, dispels phlegm and lowers qi.

Formula Analysis

Unique Combination Features First, in order to correct the disordered qi movement, this formula moves qi, descends counterflow, and calms surging. Second, in order to expel phlegm turbidity, a yin-cold pathogen, it disperses cold and resolves phlegm while rectifying qi.

Formula Applications 1. Essential pattern differentiation Zhĭ Shí Xiè Bái Guì Zhī Tāng is a commonly used formula for chest bì caused by chest yang weakness, phlegm obstruction, and counterflow qi. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of chest yang weakness, phlegm obstruction, and qi stagnation: angina pectoris, intercostal neuralgia, and non-suppurative costal cartilage inflammation. 4. Cautions and contraindications This formula is not appropriate for chest bì due to yang deficiency with weak qi.

Associated Formulas Guā Lóu Xiè Bái Bái Jiŭ Tāng (Trichosanthes, Chinese Chive and White Wine Decoction, 瓜蒌薤⽩⽩酒汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Decoct all of the ingredients simultaneously, reduce down to two sheng of the decoction, and drink while it is warm.

[Actions] Unblocks yang and dissipates masses, moves qi and dispels phlegm. [Applicable Patterns] Chest bì. Symptoms include: panting, cough, spitting, chest and back pain, shortness of breath, the cùn pulse is deep and slow, and the guān pulse is tight and rapid. Guā Lóu Xiè Bái Bàn Xià Tāng (Trichosanthes, Chinese Chive and Pinellia Decoction, 瓜蒌薤⽩半夏汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Decoct all of the ingredients simultaneously and reduce to four sheng. Drink one sheng, warm (ed), three times per day. [Actions] Unblock yang and dissipates masses, dispels phlegm and loosens the chest. [Applicable Patterns] Chest bì. Symptoms include: severe phlegm-turbidity chest pain radiating to the back, and unable to lie down flat.

Guā Lóu Xiè Bái Bái Jiŭ Tāng, Guā Lóu Xiè Bái Bàn Xià Tāng, and Zhĭ Shí Xiè Bái Guì Zhī Tāng all contain guā lóu and xiè bái. They have the action of unblocking yang, dissipating masses, moving qi, and dispelling phlegm. They all treat chest yang weakness, phlegm obstruction, and qi induced chest bì. Guā Lóu Xiè Bái Bái Jiŭ Tāng is the basic formula used to unblock yang and dissipate masses, move qi, and dispel phlegm. It is best for chest bì with a mild pattern of qi and phlegm obstruction manifesting as chest pain, panting, and shortness of breath. Guā Lóu Xiè Bái Bàn Xià Tāng is based on the former formula with bàn xià, which more strongly dispels phlegm and dissipates masses. It is good at treating chest bì with severe phlegm-turbidity manifesting as chest pain radiating to the back, unable to lay down flat. Zhĭ Shí Xiè Bái Guì Zhī Tāng is based on Guā Lóu Xiè Bái Bái Jiŭ Tāng with the white wine removed and zhĭ shí, guì zhī and hòu pò added. The action to unblock yang and dissipate masses becomes stronger so it can lower qi, dispel phlegm, disperse pĭ, and relieve abdominal fullness. Therefore, it is suitable to treat patterns of chest bì with cloying phlegm and severe counterflow qi manifesting fullness and pain in the chest, chest pain radiating to the back, and a feeling of qi rising from the hypochondria to the heart and chest.

Case Studies Chest bì Mr. Wang, 56 years old had his initial visit on November 20th, 1981. He suffered from paroxysmal heart disease for three years. He was diagnosed with coronary heart disease, hypertension, and atherosclerosis in a city hospital. Recently, he had frequent heart pain, chest oppression, shortness of breath, cold feeling of the head, and sweating. Nitroglycerin tablets could not help his condition. Visual exam showed him to have excessive body fat,

pale complexion, and drooping spirits. His tongue was pale with petechiae, the coating was white and greasy, and the pulse was soggy, slow, and irregularly intermittent. His blood pressure was 25.3/16.0 kPa (190/120 mmHg); cholesterol was 7.28 mmol/L; ECG measured sinus bradycardia, coronary insufficiency, and an incomplete right bundle branch block. Chest X-rays revealed that the left first and second auricles were enlarged. Fundus examination showed atherosclerotic change. He was given a Western diagnosis of angina, high coronary heart disease, and atherosclerosis. The TCM pattern was diagnosed as phlegmturbidity, blood stasis, and qi stagnation obstructing the chest yang. The treatment was aimed to warm and unblock the chest yang and dissolve phlegm to unblock vessel. The prescription included the following medicinals: guā lóu 50 g, xiè bái 15 g, guì zhī 10 g, zhĭ qiào 15 g, bàn xià 15 g, dān shēn 30 g, chuān xiōng 15 g, and jú hóng 25 g. He was given six doses and instructed to prepare the formula as a decoction. At his follow-up visit, he reported that his heart pain was reduced after taking the six doses of the decoction. The chest oppression and shortness of breath were both alleviated. Therefore, the same prescription was prescribed. At his third visit, after continuously taking the formula for one month, the precordial pain and shortness of breath disappeared and his mood improved. His pulse was deep and thin and an ECG test measured normal.1 Comments: This was a case with constitutional phlegm accumulation blocking the qi movement. As a result, the patient developed chest oppression and shortness of breath. A white and greasy tongue coating and a soggy, rapid pulse are signs of phlegm-turbidity while the dark tongue with stasis spots is a sign of heart blood stasis. The onset of frequent heart pain is caused by blockage of the heart channel. Zhĭ Shí Xiè Bái Guì Zhī Tāng was applied to warm and unblock the chest yang, dissolve phlegm, and rectify qi.

Jú hóng was added to dissolve phlegm, dān shēn and chuān xiōng were used to invigorate blood and dissolve stasis to dredge the heart channel. All the medicinals cooperate together to resolve phlegm-turbidity, strengthen the chest yang, and dredge chest bì to foster a spontaneous cure.

Bàn Xià Hòu Pò Tāng 半夏厚朴汤Pinellia and Officinal Magnolia Bark Decoction Source Text Essentials from the Golden (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

1 Dong Jian-hua, Wang Yong-yan. Elite Medical Cases of Famous Modern TCM Doctors. Vol.6. 中国现代名中医医案精华六. Beijing: Beijing Publishing House; 2002. p. 687.

reparation and Administration Prepare as a decoction.

Formula Indications Bàn Xià Hòu Pò Tāng is indicated for plum-stone qi (globus hystericus). The symptoms are fullness and tightness in the chest and diaphragm, coughing, and vomiting. The tongue coating is white and moist or white and glossy. The pulse is wiry and slow or wiry and slippery.

Analysis of Fundamental Pattern Pathogenesis

Plum-stone qi primarily manifests a sensation that something is lodged, obstructing the throat that can be neither removed through emesis nor swallowing. However, there is no problem swallowing food. This pattern is often caused by stagnant qi and phlegm obstructing the throat. Emotional frustration leads to liver qi stagnation. The lung and stomach fail to diffuse and govern descent; therefore, the body fluid cannot be distributed normally. It will instead accumulate as phlegm and bind with qi to obstruct the throat. This is why the patient has the sensation. When the lung and stomach fail to diffuse and govern descent, the qi movement in the chest is disturbed and becomes pathological. The result is chest and rib-side fullness and oppression, cough, wheezing, nausea, and vomiting. According to the pathogenesis of this pattern, the treatment principle is to move qi, dissipate masses, direct counterflow downward, and dissolve phlegm.

Formula Actions Moves qi and dissipates masses, directs counterflow downward and dissolves phlegm.

Formula Analysis

Unique Combination Features Primarily, this formula rectifies qi and dissolves phlegm, treating qi and phlegm simultaneously. Secondarily, it uses acrid and bitter medicinals that descend while moving qi.

Formula Applications 1. Essential pattern differentiation Bàn Xià Hòu Pò Tāng is commonly used to treat plum-stone qi caused by binding constraint of phlegm and qi. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of binding constraint of phlegm and qi: hysteria, gastric neurosis, chronic pharyngitis, chronic bronchitis, and esophageal spasm. 4. Cautions and contraindication This formula contains many medicinals that are acrid-warm and bitterdrying. They are only suitable in cases of binding constraint of qi and phlegm without heat. This formula is not applicable for patients suffering plum-stone qi due to qi constraint transforming into fire, yin damage, and insufficient fluid with red cheeks, bitter taste in the mouth, and a red tongue with a scanty coating.

Case Studies 1. Plum-stone qi 32-year-old Ms. Zhao suffered with a sensation that something was lodged, obstructing her throat that could neither be removed through emesis nor swallowing. Her neck was rigid, she had chest oppression, and her pulse was choppy. Her symptoms presented exactly as the zhì luán (baked meat syndrome, 炙脔) described in the Essentials from the Golden Cabinet. Three doses of a modified Bàn Xià Hòu Pò Tāng were prescribed. The ingredients

included: washed bàn xià 9 g, hòu pò 9 g, fú líng 12 g, zĭ sū yè 6 g, shēng jiāng 6 g, gé gēn 9 g, huáng yào zĭ 9 g, and fèng huáng yī 3 g. At her second visit she reported that all the symptoms had improved. The patient was advised to stay in a good mood in order to prevent further recurrence. Another three doses of the previous formula were prescribed with an addition of lǜ è méi 5 g.1 1 Dong Jian-hua, Wang Yong-yan. Elite Medical Cases of Famous Modern TCM Doctors. Vol.1 中国现代名中医医案精华⼀. Beijing: Beijing Publishing House; 1990. p. 216.

Comments: This case of plum-stone qi was caused by binding constraint of qi and phlegm in the throat. Bàn Xià Hòu Pò Tāng is a formula appropriate for plum-stone qi. The application of this formula in prescriptions can move qi, dissipate masses, direct counterflow downward, and dissolve phlegm. Due to her neck rigidity, gé gēn was added to increase neck flexibility. Huáng yào zĭ, fèng huáng yī, and lǜ è méi were added to enhance the prescription’s ability to soothe the liver and dissipate masses. 2. Neck mass (thyroid mass) Ms. Yu, 29 years old, had her initial visit October 27th, 1977. She reported a neck mass she had for three years. The mass was about 3 cm in diameter and hard, accompanied with profuse phlegm and a hoarse voice. It was diagnosed as thyroid nodules and surgical removal was recommended. She had dull pain over her stomach and recent diarrhea. Her pulse was long and her tongue coating was white. The soothing method was applied with the following prescription: jiāng bàn xià 9 g, hòu pò 4.5 g, zĭ sū gĕng 6 g, fú líng 12 g, chén xiāng qū 9 g, xià kū căo 12 g, zàng qīng guŏ 6 g, zhì gān căo 9 g, cāng zhú 4.5 g, and Băo Hé Wán (wrapped) 12g. She came for a followup visit on November 29th, 1977. After taking fifteen doses, the stomachache and diarrhea were gone and the mass had reduced to 1.5 cm×2.5 cm. More doses of the previous formula were applied without Băo Hé Wán, cāng zhú

removed, and bái zhú 6g added. She came for her third visit on February 25th, 1978. Although the mass reduced to l cm in diameter, the phlegm remained and her tongue coating was white. Five doses of modified Bàn Xià Hòu Pò Tāng and Xiāo Luŏ Wán (Scrofula-Resolving Pill, 消瘰丸) were prescribed as follows: jiāng bàn xià 9 g, hòu pò 6 g, fú líng 12 g, zĭ sū gĕng 6 g, xià kū căo 6 g, xuán shēn 9 g, mŭ lì 12 g, hăi zăo 6 g, zhè bèi mŭ 9 g, and shēng jiāng 2 pieces. 1 Comments: This is a case where a mass on the neck was caused by binding constraint of qi and phlegm. Modified Bàn Xià Hòu Pò Tāng was chosen to rectify qi and dissipate masses. Due to her hoarse voice, zàng qīng guŏ and zhì gān căo were added to benefit the throat and restore her voice. Recently the patient had a stomachache and diarrhea, so cāng zhú and Băo Hé Wán were added to remove dampness and reduce the food stagnation. Her follow-up visit showed that the mass shrank, her voice improved, and her stomachache and diarrhea were cured. Therefore, cāng zhú and Băo Hé Wán were removed and bái zhú was added to fortify the spleen and reinforce healthy qi. After taking the second formula the mass reduced further; therefore, modified Bàn Xià Hòu Pò Tāng and Xiāo Luŏ Wán were applied for their reducing and dissipating effect.

Tiān Tái Wū Yào Săn天台乌药散Tiantai Combined Spicebush Root Powder a.k.a. Wū Yào Săn (Combined Spicebush Root Powder, 乌药散) Source Text Comprehensive Recording of Divine Assistance (Shèng Jì Zŏng Lù, 圣 济总录)

Formula Ingredients

1 He Ren, Zhang Zhi-min, Lian Jian-wei. Comments on Hundreds of Medical cases of Formulas from Essentials from the Golden Cabinet ⾦匮⽅百家医案评议. Hangzhou: Zhejiang Science and Technology Press; 1991. p. 393.

Preparation and Administration Break apart the bā dòu slightly and stir-fry them with chuān liàn zĭ in wheat bran. Then sift out the bā dòu and wheat bran, grind into powder with the rest of the ingredients, and mix evenly. Take 1 qian (3g) each time with warm wine (Modern use: chuān liàn zĭ is stir-fried with bā dòu until black,

sift out the bā dòu, add the rest of the ingredients, prepare as a decoction, and then add an adequate amount of rice wine when it is ready to be taken.)

Formula Indications Tiān Tái Wū Yào Săn is indicated for small intestinal shàn qì due to cold congealing and stagnant qi in the liver channel. The symptoms are lesser abdomen pain dragging to the testicle(s), a feeling that the testicles are distended and dropped unevenly, or lesser abdomen pain. The tongue is pale with a white coating and the pulse is deep and slow or wiry. This formula is also used for painful menstruation and abdomen mass due to cold congealing and qi stagnation.

Analysis of Fundamental Pattern Pathogenesis The foot jueyin liver channel reaches the lesser abdomen and connects with the genital organs. If cold pathogens are lodged within the liver channel, the qi movement will be blocked to cause lesser abdominal pain, dragging pain in the testis, and a feeling that they are dropped unevenly with distention as a result of small intestinal shàn qì. Therefore, it is said that “all shàn diseases are related to the liver channel” [3] (Confucians’ Duties to Their Parents, Rú Mén Shì Qīn, 儒门事亲). The therapeutic principles are to move qi, soothe the liver, disperse cold, and relieve pain.

Formula Actions Moves qi, soothes the liver, disperses cold, and relieves pain.

Formula Analysis

Unique Combination Features This formula is composed of a large amount of qi-moving medicinals and a few cold-dissipating medicinals, utilizing the method of moving qi and warming the channels.

Formula Applications 1. Essential pattern differentiation Tiān Tái Wū Yào Săn is a formula commonly used to treat testicular hardness and pain caused by congealed cold and qi stagnation in the liver channel. This clinical pattern is marked by:

● lesser abdomen pain dragging to the testicle(s) ● pale tongue with white coating ● deep, wiry pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of congealed cold and qi stagnation in the liver channel: inguinal hernia, orchitis, epididymitis, gastrointestinal disorders, intestinal cramps, and dysmenorrhea. 4. Cautions and contraindications The ingredients in this formula have a warm and dispersing nature. It is not applicable for patients diagnosed with testicular hardness and pain due to liver-kidney yin deficiency.

Associated Formulas Sì Mò Tāng (Four Milled Ingredients Decoction, 四磨汤) [Source] Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅) [Ingredients]

[Preparation and Administration]

Grind the four medicinals with water and prepare them as decoction. [Actions] Moves qi, lowers counterflow qi, loosens the chest, and dissipates masses. [Applicable Patterns] Binding constraint of liver qi. Symptoms include: chest oppression, wheezing, epigastrium pĭ and fullness, and no desire to eat or drink. Tiān Tái Wū Yào Săn and Sì Mò Tāng both move qi and soothe the liver to treat syndromes of liver qi constraint and stagnation. Tiān Tái Wū Yào Săn moves qi, soothes the liver, dissipates cold, and relieves pain. It is used for small intestinal shàn qì due to congealed cold and qi stagnant in the liver channel. Sì Mò Tāng can move qi and lower counterflow qi. In addition, it can boost qi and reinforce zheng qi since it contains rén shēn. It treats both pathogenic qi and zheng qi and may be used for patterns of binding constraint and liver qi with counterflow qi.

Case Studies 1. Shàn qì (hernia) Mr. Wu appeared for his initial visit on May 30th. He reported lingering hernia, chest, and rib-side oppression, severe pain in the right lesser abdomen, and swollen testis. His pulse was deep and wiry and his tongue coating was white and greasy. Since the root of his disease was deep, the therapeutic method should be to immediately soothe the liver and rectify qi. He was prescribed: chuān liàn zĭ 9 g, mù tōng 3 g, wū yào 9 g, jú hé 9 g, jú yè 9 g, guăng mù xiāng 4.5 g, qīng pí 4.5 g, xiăo huí xiāng 4.5 g, lì zhī hé 9 g, shān zhā hé 9 g, and chì fú líng 9 g. He came for a second visit on June

2nd. His syndrome had improved a lot after taking the liver-soothing and qirectifying formula, so the same formula with an addition of bái sháo 9 g was prescribed. His third visit was on June 9th: The shàn qì pain was much alleviated. He was then prescribed: guăng mù xiāng 4.5 g, bā jiăo huí xiāng 4.5 g, xiăo huí xiāng 4.5 g, chuān liàn zĭ (cut up and fried) 9 g, mù tōng 6 g, chì fú líng 9 g, zé xiè 9 g, jú hé 9 g, jú yè 9 g, lì zhī hé 9 g, shān zhā hé 9 g, qīng pí 4.5 g, wū yào 9 g, and chì sháo 9 g.1 Comments:This case of shàn qì was caused by pathogenic cold. The collaterals of the liver channel connect to the genital organs and reach upwardly to the lesser abdomen. Cold pathogens cause constriction, so it leads to dragging pain in the lesser abdomen and testicles. Fang Gong-fu, a well-known physician from Shanghai (1889–1948), applied the method of rectifying qi and soothing the liver to treat it. The formula was composed of Tiān Tái Wū Yào Săn without gāo liáng jiāng, bā dòu, and bīng láng. Lì zhī hé, jú yè, jú hé, shān zhā hé, and chì sháo were added to more effectively move qi, soothe the liver, dissipate masses, and relieve pain. Chì fú líng and zé xiè were added to eliminate dampness in order to treat the coagulated cold dampness. The formula fit the pattern well, so the result was effective. 2. Stomachache 1 Wang Wen-ji. Medical Works Collection of Jin Shan County, Volume 8, Fang Gong-fu’s Medical Cases ⾦山医学摘粹卷八·⽅公溥医案. Shanghai: Jinshan County Political Consultative Committee, Health Bureau, Science and Technology Committee; 1988. p. 91.

Mr. Yun, 65 years old, had his initial visit on February 6th, 1997. He suffered from dropping pain in the lower abdomen and the feeling of a movable mass in the right groin region for three days. He believed it was small intestinal shàn qì and asked for help. Tiān Tái Wū Yào Săn was prescribed to move qi, dissipate cold, and relieve pain. The prescription was composed of: wū yào 15 g, xiăo huí xiāng 10 g, guăng mù xiāng 10 g, qīng

pí 10 g, chén pí 10 g, gāo liáng jiāng 6 g, chuān liàn zĭ 10 g, huáng qí 30 g, fried bái zhú 10 g, processed xiāng fù 10 g, bīng láng 10 g, yán hú suŏ 10 g, and zhì gān căo 5 g. He was instructed to take one dose per day, half in the morning and half in the evening. On the 6th day of his TCM treatment, he had an operation to repair an incarcerated hernia. One month later, the patient mentioned that the above prescription had worked for his stomachache. He had the stomachache for over ten years with accompanying symptoms of belching, epigastrium distention, and acid reflux following an attack of cold. He had received various medicinal treatments previously that usually worked to alleviate the stomachache while he was taking them. They would however return when he stopped taking the medicinals. As his pulse was thin, wiry, and deep, bái sháo 10 g was added into the original prescription. All of the symptoms were alleviated after two weeks of taking the medicinals. The original prescription was then prescribed for another two weeks to consolidate the effect. His one-year follow-up visit revealed that his stomachache had never reoccurred.1 Comments: Tiān Tái Wū Yào Săn moves qi, soothes the liver, dissipates cold, and relieves pain. It is indicated for small intestinal shàn qì due to congealed cold and stagnant qi. Dr. Ling held the opinion that wū yào, bīng láng, and qīng pí regulate qi, while xiăo huí xiāng and gāo liáng jiāng dispel cold. This formula can be used for stomachache because these medicinals are all effective pain relievers. It is mentioned in The Yellow Emperor’s Inner Classic: Basic Questions that pain is often caused by excess cold qi. It is said in the Essential Teachings on Diagnosis and Treatment “where there is blockage, there is pain; where there is no blockage, there is no pain.” [4] Epigastric pain, stomachache, and heart pain can all be caused by an attack of cold, a cold diet, internal stagnant heat, constitutional phlegm or blood stagnation, anger, qi stagnation, parasites, and more. If the disease is not

treated according to proper pattern differentiation, how can the disease be cured? Pathogenic cold qi stagnation is the major cause for stomachache. The main function of Tiān Tái Wū Yào Săn is to dispel cold and move qi. Therefore, modifications of this formula can obtain effective results when treating stomachache.

Jú Hé Wán 橘核丸Tangerine Seed Pill Source Text Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅)

Formula Ingredients

Preparation and Administration 1 Ling Dong-sheng. 84 Stomachache Cases Treated by Tiān Tái Wū Yào Săn 天台乌药散治疗胃 痛84例.Jiangsu Journal of Traditional Chinese Medicine. 2003; 24 (5): 29.

Grind the ingredients into a fine powder and shape into pills with liquor the size of a phoenix tree seed. Take 70 pills each dose on an empty stomach with warm liquor or salty soup. (Modern use: grind the ingredients into a fine powder and shape into small pills. Take 9 g 1-2 per day with warm

liquor or salty soup. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratio.)

Formula Indications Jú Hé Wán is indicated for cold-damp shàn qì. The testicles swell, drop to one side, and become hard as stone. There is dragging pain in the abdomen and, possibly, an enlarged scrotum. Mild cases have yellow discharge, and severe cases develop a festering abscess.

Analysis of Fundamental Pattern Pathogenesis This formula is characteristically used for the treatment of swollen testis caused by interior cold-dampness that blocks the jueyin liver channel and constrains and stagnates qi and blood. The disease is located in the kidney (testis is the external kidney) and the pathogenesis is in the liver. The liver channel reaches the lesser abdomen and surrounds the genital organs. When damp-cold obstructs the liver channel, the testis initially swell and have a dragging pain. Long standing cases will develop qi stagnation and blood stasis which cause the testis to become as hard as stone with dragging pain in the lesser abdomen. If cold-dampness and phlegm-turbidity block for a long time, pus or even an abscess will form. This formula’s syndrome pattern is long term coexisting of cold-dampness, phlegm, blood stasis, and qi stagnation. Therefore the treatment is focused on moving qi, invigorating blood, dissipating masses, and relieving pain while dispelling cold and removing dampness.

Formula Actions Moves qi and relieves pain, softens and dissipates hard masses.

Formula Analysis

Unique Combination Features This formula has a large grouping of qi-moving and blood-invigorating medicinals used in combination with those that soften and dissipate hard masses. It has a marked effect to eliminate swelling and dissipate masses.

Formula Applications 1. Essential pattern differentiation Jú Hé Wán is the common formula used to treat shàn qì due to colddampness. This clinical pattern is marked by:

● swollen testis that are dropping unevenly and hard when palpated

● dragging pain in the lesser abdomen 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of cold-dampness invading the jueyin liver channel with qi and blood stagnation: hydrocele, acute and chronic orchitis, testicular tuberculosis, and epididymitis. 4. Cautions and contraindication It is not applicable for patients who have uneven dropping of their testis but with a soft texture.

Case Studies Hyperplasia of mammary glands Ms. Li, 35 years old, had her initial visit on February 2nd, 2007. The patient had bilateral breast distention and changing waves of emotions. She suffered rib-side distention, vexation, irascibility, and insomnia for two months. Five days ago, she quarreled with her family members and her symptoms got more severe. The mass in both breasts enlarged with

unbearable distention. Her tongue was slightly red with a thin, yellow coating, and the pulse was wiry. An uneven, thick, flakeshaped tumor that was painful when pressed was found in both breasts through palpation. Color Doppler ultrasound showed bilateral hyperplasia of the mammary glands. The case was treated with six dosages of Jú Hé Wán: jú hé 15 g, hăi zăo 15 g, kūn bù 15 g, chuān liàn zĭ 15 g, hòu pò 15 g, mù xiāng 15 g, yán hú suŏ 15 g, dà zăo 15 g, zhè bèi mŭ 15 g, zhĭ qiào 12 g, táo rén 12 g, bái sháo 15 g, dāng guī 15 g, yù jīn 15 g, guā lóu 15 g, mŭ dān pí 15 g, mŭ lì 15 g, and zhī zĭ 12 g. The tumors in both breasts were significantly smaller in size and softer in texture after taking the formula. She continuously took ten dosages of the above prescription and the rib-side distention, vexation, irascibility, and insomnia disappeared. After taking another five dosages of the above prescription, all of her clinical symptoms disappeared without reoccurrence for eight years, according to the followup visit.1 Comments: Hyperplasia of mammary glands is categorized as breast lump according to TCM. The etiology and pathology are closely related with liver and kidney. Long standing emotional disorders damage the liver, bind and constrain liver qi, and stagnate the blood in the collaterals of the breast. Long-term liver qi stagnation transforms into heat and burns fluid into phlegm. Phlegm combines with stagnant qi and causes a tumor. In this case it was in the breasts. The chong mai and ren mai both reach the chest and are related to the liver and kidney. Disharmony of the chong mai and ren mai caused stagnant qi and static blood to accumulate in the breasts and form a tumor. Jú Hé Wán has been used to treat tuí shàn where external pathogens enter the liver channel and obstructs its qi and blood. Tuí shàn and breast lumps are two different diseases, but they share the pathogenesis of combined liver qi stagnation, blood constraint, and binding phlegm. Due to the principle of different diseases share a common treatment, Dr. Hua

understood the pathogenesis of breast lumps and applied modified Jú Hé Wán. In it, jú hé and chuān liàn zĭ enter the liver channel, move qi, dissipate masses, and relieve pain. Táo rén and mŭ dān pí enter blood level and move blood to dissipate nodules. Hăi zăo, kūn bù, zhè bèi mŭ, mŭ lì, and guā lóu soften hard masses and dissolve phlegm to strengthen the function to disperse swelling and remove stasis. Yán hú suŏ rectifies qi, invigorates blood, and dissipates stasis. Mù xiāng, zhĭ qiào, and yù jīn move qi, dissipate accumulation, and break masses. Zhī zĭ drains depressed fire from the liver channel. Hòu pò lowers qi and removes dampness. Dà zăo calms the center and harmonizes the other ingredients. All the medicinals cooperate and reach the liver channel in order to collectively move qi, invigorate blood, dissolve phlegm, remove dampness, disperse swelling, and soften and dissipate hard masses in order to regulate the free flow of qi and blood. The symptoms disappeared and a satisfactory result was achieved.

Nuăn Gān Jiān 暖肝煎Liver-Warming Decoction Source Text The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书)

Formula Ingredients

1 Hua Ming-zhen. 120 Cases of Hyperplasia of Mammary Glands Treated by Jú Hé Wán Modification 橘核丸化裁治疗乳腺增⽣120例. Hubei Journal of Traditional Chinese Medicine. 2008; 30 (7): 49.

Preparation and Administration Add 3-5 slices of shēng jiāng, and prepare as a decoction.

Formula Indications Nuăn Gān Jiān is indicated for patterns of liver and kidney insufficiency with cold coagulation in the liver channel. Symptoms include cold pain in the testis, lower abdominal pain, fear of cold, and a preference

for warmth. The tongue is pale with a white coating, and the pulse is deep and slow.

Analysis of Fundamental Pattern Pathogenesis This formula treats a pattern of liver and kidney insufficiency, lodged cold in the liver channel, and obstruction of qi. Cold is a yin pathogen that characteristically induces contraction. When the liver and kidney are insufficient, cold can easily lodge in the liver channel to cause disharmony and block its qi. The symptoms therefore manifest as cold pain in the testis, lower abdominal pain, and shàn qì pain. The treatment is to supplement the liver and kidney, dissipate cold coagulation, and move qi stagnation.

Formula Actions Warms and supplements the liver and kidney, moves qi and relieves pain.

Formula Analysis

Unique Combination Features This formula simultaneously supplements, disperses cold, and moves qi. It warms and supplements the liver and kidney in order to treat the root. It also moves qi and dispels cold in order to treat the branch.

Formula Applications 1. Essential pattern differentiation Nuăn Gān Jiān is commonly indicated for pain of the lower abdomen or testicular pain due to the liver and kidney insufficiency, congealing cold, and qi stagnation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver and kidney insufficiency, congealed cold, and qi stagnation: varicocele, orchitis, epididymitis, hydrocele, and inguinal hernia. 4. Cautions and contraindication It is not applicable for a scrotum that is swollen, red, and painful due to damp-heat pouring downward.

Comparison & Contrast Tiān Tái Wū Yào Săn vs. Jú Hé Wán vs. Nuăn Gān Jiān

Case Studies 1. Spermatic neuralgia A 48-year-old male farmer had his initial visit on December 24th, 1989. The patient had right testicular pain with dragging pain in the lower abdomen for two months. The local hospital diagnosed it as spermatic neuralgia. Western medicine, medicinals, and acupuncture treatments had no effect. Examination showed that the right testicle had unbearable dragging pain that dragged into the lower abdomen causing him to bend over at the trunk when walking. He was not able to stand straight. He suffered a dropping and cold sensation in the testis, weakness in lumbar and legs, cold extremities, slight poor appetite, and normal sleep, stools and urination. The

testis and epididymis were developed normally. There was miserable, cramping pain in spermatic tendon when palpated that dragged to the lower abdomen. The tongue was pale with a moist, glossy coating and the pulse was deep and wiry. It was a pattern of cold congealing the liver and kidney and inhibiting qi movement. The treatment was to warm the liver and kidney, move qi, and relieve pain. A modification of Nuăn Gān Jiān was prescribed, composed of: dāng guī 12 g, gŏu qĭ zĭ 12 g, xiăo huí xiāng 9 g, ròu guì 6 g, wū yào 9 g, chén xiāng 3 g, fú líng 12 g, quán xiē 5 g, wú gōng 1 piece, and shēng jiāng 3 slices. He was instructed to take one bag per day as a decoction. After seven dosages, the pain was alleviated by more than fifty percent and all of the symptoms were relieved. He took another seven dosages and the pain was cured without reoccurrence in the two years previous to his follow-up visit. 1 Comments: This is a case of spermatic neuralgia with the chief symptoms of testicular pain dragging to the lower abdomen. It falls into the category of shàn in TCM. The pattern is cold congealing the liver and kidney and inhibited qi movement. Therefore, Nuăn Gān Jiān was used to warm the liver and kidney, move qi, and relieve pain. Quán xiē and wú gōng were added to arrest convulsion, unblock the collaterals, and relieve pain with efficacious results. 2. Penis contracture 1 Zou Tao-sheng. Examples of Nuăn Gān Jiān Modification Treating Spermatic Neuralgia 暖肝 煎加味治愈精索神经痛. Jiangxi Journal of Traditional Chinese Medicine. 1994; 25(6): 16.

Mr. Zhou, a 50-year-old married man, came for an initial visit on March 20th, 1980 and was hospitalized. The patient had spastic pain with a shrinking penis that has been repeating its onset for half a year. The patient had spastic pain and a shrinking pain in the penis since September 1979 after the patient moved bricks in the rain. The external appearance showed that

the penis had disappeared, the lumbar was sore, and he suffered frequent urination. The onset of the spastic, shrinking penis started from the initial incident in 1979 and kept repeating with unbearable cramping pain, forcing him to take pain killers. The time it takes for his penis to shrink varies from ten minutes to five hours. The patient used a T-shaped bandage and a hot water bag to reduce the pain. He has had diarrhea four to five times per day since February 1980. His pulse was wiry and thready. His tongue was slightly purple with teeth marks and the coating was thin and white. The symptoms and pulse all indicated excess yin-cold. His pattern was differentiated as liver and kidney deficiency-cold and the treatment method selected was to warm the liver and kidney and relieve pain. He was prescribed three bags of a formula composed of: fù zĭ 15 g, ròu guì 15 g, xiăo huí xiāng 15 g, chén xiāng 15 g, dāng guī 15 g, gŏu qĭ zĭ 15 g, wú zhū yú 15 g, niú xī 15 g, yán hú suŏ 15 g, jú hé 15 g, and lì zhī hé 15 g. At his second visit on March 31st, the patient mentioned that after taking three bags of medicinals, the lumbar pain was gone, had spastic pain in the medial thigh, and had no shrinking of his penis for two days. He was prescribed another three bags of the above prescription with bŭ gŭ zhī 25 g, ròu dòu kòu 25 g, and chuān liàn zĭ 5 g added. At his third visit on April 3rd, the patient mentioned he went to a public bath and his penis shrank for ten minutes but there was no pain. The pulse was soggy and rapid and the tongue was slightly purple. Therefore another four doses of the previous prescription with the removal of yán hú suŏ, lì zhī hé, and jú hé was prescribed. On the morning of April 5th, the penis shrank again for twenty minutes. However, the penis and glans were apparent, measuring 2.5 cm. His penis did not shrink again ever since. His diarrhea also stopped. The patient stayed in the hospital for another two weeks and was cured.1

Comments: The patient was attacked by cold after moving bricks in the rain, causing a pathological cold invasion. The pathogenesis was cold coagulating within the jueyin and excessive pathological yin-cold disturbed the shaoyin, liver, and kidney channels to create the syndrome. It was treated by warming the channels, dissipating cold, rectifying qi, and relieving pain. Fù zĭ and wú zhū yú were added into Nuăn Gān Jiān to strengthen its effect to warm the channels and dissipate cold. Jú hé, lì zhī hé, yán hú suŏ, and chuān liàn zĭ were added to strongly rectify qi, dissipate masses, and relieve pain. Niú xī guides the medicinals downward, invigorates blood, and unblocks the channels. The patient was cured after a total of ten doses, and according to the follow-up visit, was without reoccurrence for three years.

Jiā Wèi Wū Yào Tāng 加味乌药汤Supplemented Combined Spicebush Root Decoction a.k.a. Jiā Wèi Wū Chén Tāng (Supplemented Combined Spicebush and Root and Aquilaria Wood Decoction, 加味乌沉汤) Source Text Fine Formulas of Wonderful Efficacy (Qí Xiào Liáng Fāng, 奇效良⽅), recorded in A Compendium of Female Disorders (Jì Yīn Gāng Mù, 济阴纲 ⽬)

Formula Ingredients

Preparation and Administration Add 3 pieces of shēng jiāng, and prepare it as a decoction. 1 Chen Yong-qi. Nuăn Gān Jiān Treating Two Cases of Shrinking Penis 暖肝煎治愈阴茎缩入2 例. Journal of Traditional Chinese Medicine. 1982; (11): 32.

Formula Indications

Jiā Wèi Wū Yào Tāng is indicated for painful menstruation. Signs and symptoms are lesser abdominal pain before or in the early menstrual period, distention more than pain, or with chest, ribside, and breast tenderness. The tongue is pale with a thin, white coating, and the pulse is wiry and tight.

Analysis of Fundamental Pattern Pathogenesis Painful menstruation is commonly due to disorders of qi and blood circulation. Emotional disorders can cause binding constraint of the liver qi that obstructs it, blood stasis, stagnation of the chong mai and ren mai channels, obstructed menses in the uterus causing pain, lesser abdomen distention pain, and radiating pain of the chest and rib-side. If the qi stagnation pain is severe, the pulse will be wiry, long, and tight. This formula is designed to treat the liver constraint and qi stagnation type of painful menstruation. The treatment method is to soothe the liver, resolve constraint, regulate the menstruation, and relieve pain.

Formula Actions Moves qi and invigorates blood, regulates the menstruation, and relieves pain.

Formula Analysis

Formula Applications 1. Essential pattern differentiation Jiā Wèi Wū Yào Tāng is indicated for painful menstruation due to liver constraint and qi stagnation. This clinical pattern is marked by:

● distending lesser abdomen pain before menstruation ● more distention than pain 2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of liver constraint, qi stagnation, and blood stagnation: dysmenorrhea, amenorrhea, and delayed menstruation. 4. Cautions and contraindications This formula is not suitable for the qi and blood insufficiency type of abdominal pain after menstruation period.

Case Studies Dysmenorrhea Miss Hu, a 22-year-old unmarried female, had her initial visit on April 21st, 1986. The patient had abdominal pain a week before every menstruation period for two years. She had not had any positive effects from a variety of treatments. In the recent six months, the patient had severe distending lesser abdominal pain before her menstruation period. There was more distention than pain and the menses were scanty with difficult flow. She was depressed, vexed, irascible, had a poor appetite and digestion, and chest, rib-side, and breast tenderness. The tongue was purple dark, and the pulse was deep and wiry. Her former doctor prescribed Gé Xià Zhú Yū Tāng (Expelling Stasis Below the Diaphragm Decoction, 膈下逐瘀汤) with no effect. This is a pattern of qi and blood stagnation that required qi to be treated first. The method was to rectify qi, unblock constraint, soothe the liver, and unblock stagnation. The prescription was a modification of Jiā Wèi Wū Yào Tāng, composed of wū yào 10 g, xiāng fù 10 g, shā rén 10 g, yán hú suŏ 10 g, bīng láng 10 g, gān căo 10 g, mù xiāng 10 g, and hŭ pò 5 g. The medicinals were ground into powder and infused. Her pain was relieved after two doses and the rest of her symptoms reduced. Two more dosages of the

same prescription were given for her to take before the onset of her period over the next three cycles. Thereafter, she was cured.1 Comments: This is an emotional disorder case with liver qi blockage, qi stagnation, blood stagnation, disturbed chong mai and ren mai flow, and blood stasis in the uterus causing pain. Golden Mirror of the Medical Tradition - Essential Teachings on the Treatment of Gynecology noted, “Distending abdominal pain before the menstruation period is due to qi and blood stagnation. If the distention is more than pain, it is more qi blockage than blood. Jiā Wèi Wū Yào Tāng is suitable to open it.” [5] Thereby, Jiā Wèi Wū Yào Tāng was selected with hŭ pò added. On one hand it soothes the liver and resolves constraint in order to regulate qi flow and treat the abdominal distention. On the other hand, hŭ pò invigorates blood and dispels stasis so the pain would be automatically relieved after the stasis is gone. 1 Ma Feng-you. Examples of Jiā Wèi Wū Yào Tāng Treating Menstruation Disease 加味乌药汤 治疗⽉经病举隅. Fujian Journal of Traditional Chinese Medicine. 1992; 23(1): 35.

Section 2 Qi-Descending Formulas Sū Zĭ Jiàng Qì Tāng 苏⼦降⽓汤Perilla Fruit QiDescending Decoction a.k.a. Zĭ Sū Zĭ Tāng (Perilla Fruit Decoction, 紫苏⼦汤) Source Text Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng,备急千⾦要⽅), recorded by Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平 惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind all the above medicinals into thin powder. Mix 2 qian (6 g) with 1.5 cups of water. Add 2 pieces of shēng jiāng, 1 piece of dà zăo, and 5 pieces of zĭ sū yè. Decoct down to 8 fen and take as needed. (Modern use: add 2 pieces of shēng jiāng, 1 piece of dà zăo, and 2 g of zĭ sū yè. It can also

be prepared as a decoction by adjusting the medicinal quantities based on their original ratios.)

Formula Indications Sū Zĭ Jiàng Qì Tāng is indicated for coughing or wheezing in patterns of upper excess and lower deficiency. The symptoms are phlegm-drool accumulation, chest and diaphragm fullness and oppression, coughing, panting, shortness of breath, and exhaling more than inhaling. It is accompanied by lumbago, weakness in the legs, fatigue, lassitude, or swollen limbs. The tongue coating is glossy, white or greasy, white, and the pulse is wiry and slippery.

Analysis of Fundamental Pattern Pathogenesis Upper excess refers to phlegm-drool accumulation in the lung that occurred because the lung lost its function of dispersing. It causes fullness and oppression in the chest and diaphragm, cough, panting, and a large amount of phlegm. The tongue coating is glossy, white or greasy, white, and the pulse is wiry and slippery. Lower deficiency refers to kidney yang deficiency in the lower jiao. First, the kidney fails to govern qi reception and the patient exhales more than inhales and has shortness of breath. Second, the kidney fails to govern the bones and lumbago and weakness in legs are the result. Third, the kidney fails to govern water and water is not transformed by qi. Therefore, water doesn’t diffuse and accumulates as phlegm or it floods the exterior to cause edema. The pathogenesis of this formula pattern is phlegm-drool accumulation in the lung and kidney yang insufficiency. It is a pattern of upper excess and lower deficiency, however, it is focused on upper excess. So the strategy should focus on directing qi

downward, dispeling phlegm, relieving cough and panting and then address the kidney qi.

Formula Actions Directs qi downward, dispels phlegm, relieves cough and panting.

Formula Analysis

Unique Combination Features

This formula simultaneously directs qi downward and dispels phlegm to treat the branch, and warms the kidney and supplements deficiency to treat the root. While it addresses both the upper and lower jiao simultaneously, it is focused on the branch located in the upper jiao. Sweet, moist medicinals are used in conjunction with the large group of bitter, warm, acrid, dry medicinals in order to prevent excessive dryness from developing.

Formula Applications 1. Essential pattern differentiation Sū Zĭ Jiàng Qì Tāng is commonly indicated for patterns of upper excess and lower deficiency. This clinical pattern is marked by:

● chest oppression ● profuse loose white phlegm ● white, glossy or white, greasy tongue 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of phlegm-drool accumulation in the

lung and kidney yang insufficiency: chronic bronchitis, emphysema, and bronchial asthma. 4. Cautions and contraindications This formula has warm and drying properties and is focused on directing qi downward and dispelling phlegm. It is not applicable for patients who suffer either with a lung-kidney yin deficiency type of cough and panting or lung heat with phlegm and wheezing.

Case Studies Chronic bronchitis Mr. Zhang, 42 years old, had her initial visit on September 20th, 1969. She had chronic bronchitis and suffered with an onset of coughing every autumn as it got cold. She had symptoms of phlegmdrool accumulation, lung qi obstruction, and frequent coughing and panting. The cùn pulse was wiry and slippery, and the tongue was moist, enlarged, and teeth-marked. Sū Zĭ Jiàng Qì Tāng was prescribed, composed of: zĭ sū zĭ 7.5 g, zhì gān căo 6 g, bàn xià 7.5 g, dāng guī 4.5 g, ròu guì 4.5 g, huà jú hóng 4.5 g, qián hú 3 g, hòu pò 3 g, and shēng jiāng 3 slices. Four dosages were taken as a water decoction. The coughing and wheezing were relieved after taking the medicinals. She was prescribed another four dosages of the same prescription at her follow-up visit. The coughing and panting stopped. She was advised to take the same prescription in the future whenever there is a recurrence of wind cold attack. 1 1 China Academy of Traditional Chinese Medicine. Collection of Yue Mei-zhong Medical Cases 岳美中医案集. Beijing: People’s Medical Publishing House; 1978. p. 110.

Comments: The patient was over 40 years old and had chronic coughs that have come on during cold weather. Chronic disease often relates to

deficiency, so there must be interior deficiency. The most common interior deficiency causes for cough is spleen-kidney deficiency. Coughing due to internal damage is often accompanied with phlegm-rheum. Rheum is a yin pathogen that easily damages yang, especially spleen-kidney yang. She had a reoccurrence of cough caused by cold attack with the symptoms of frequent coughing and wheezing and phlegm-drool accumulation. The enlarged, moist tongue and wiry, slippery cùn pulse indicates that phlegm-rheum was blocking the lung. Spleen-kidney yang deficiency is located in the lower jiao and phlegm blocking lung qi is located in the upper jiao. An upper excess and lower deficiency pattern thereby manifest. Therefore, Sū Zĭ Jiàng Qì Tāng was prescribed to direct qi downward and dispels phlegm and to warm and supplement the spleen and kidney. Clinically, an acute exacerbation of chronic disease is often due to the co-existence of deficiency and excess. The treatment should eliminate pathogenic factors and support vital qi. It is important not to harm the vital qi while expelling pathogenic factors and not to stagnate the pathogenic factors when strengthening the vital qi.

Dìng Chuăn Tāng 定喘汤Wheezing-Arresting Decoction Source Text Numerous Miraculous Prescriptions for Health Cultivation (Shè Shēng Zhòng Miào Fāng, 摄⽣众妙⽅)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications Dìng Chuăn Tāng is indicated for wheezing and panting due to phlegmheat accumulation in the lung. The symptoms are wheezing and panting, cough, phlegm with heavy breathing, thick yellow phlegm, and slight

aversion to wind. The tongue coating is yellow and greasy, and the pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis This formula treats wheezing and panting due to constitutional phlegmheat accumulation, frequent onset of wind-cold, and lung qi obstruction leading to poor dispersion. Therefore, the symptoms are wheezing and panting, cough and profuse yellow phlegm. The tongue coating is yellow and greasy, and the pulse is slippery and rapid. While the Dìng Chuăn Tāng pattern covers both the exterior and interior, phlegm-heat accumulation and lung failing to diffuse and govern descent is the major pathogenesis. Therefore, both the method and formula focuses on diffusing the lung and directing qi downward, clearing heat, and dissolving phlegm in combination with diffusing and dissipating exterior pathogens.

Formula Actions Diffuses the lung and directs qi downward, clears heat, and dissolves phlegm.

Formula Analysis

Unique Combination Features This formula combines descending, clearing, astringent, and dispersing medicinals that simultaneously descend, ascend, disperse, and astringent qi. It has strong effect to direct qi downward and to relieve panting and cough.

Formula Applications 1. Essential pattern differentiation Dìng Chuăn Tāng is a common formula used to treat cough and panting due to phlegm-heat accumulation. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is commonly used in the following biomedically defined disorders when the patient shows signs of phlegm-heat accumulation in the lung: bronchial asthma, asthmatic bronchitis, etc. 4. Cautions and contraindications It is not applicable for patients with chronic asthma due to lung-kidney yin deficiency.

Comparison & Contrast Sū Zĭ Jiàng Qì Tāng vs. Dìng Chuăn Tāng

Xiăo Qīng Lóng Tāng vs. Dìng Chuăn Tāng

Case Studies Asthma Ms. Chen, a 15-year-old female, had her initial visit on July 12th, 1976. The patient suffered asthma since she was 3 years old. It started with mild symptoms but worsened year by year. When an asthma attack occurs, she has shortness of breath, wheezing with a phlegmy rattling sound, unable to lie down flat, and poor appetite. Every spring and autumn it exacerbates, and only is relieved by drugs such as aminophylline and ephedrine that treat cough and asthma, and antibiotics like penicillin and streptomycin. The patient had an asthma attack recently because of external wind-cold invasion. Her symptoms included open mouth breathing while lifting her shoulders, wheezing, and heavy breathing. She had profuse thick phlegm, a pale complexion, the tongue was red with a yellow, greasy coating, and the pulse was thready and wiry. Both lungs whistled, and rales were observed during an examination. She had a pattern of interior hidden phlegm stagnation that transformed into heat. When there was a wind-cold invasion, it initiated the asthma attack. It was a condition of lung heat and wind-cold with a deficient root and excess branch. The treatment strategy was to treat the branch as an emergency. The first treatment was to diffuse the lung, clear heat, and relieve cough and panting. She was prescribed six doses of modified Dìng Chuăn Tāng composed of má huáng 9 g, bái guŏ 3 pieces (smashed), huáng qín 9 g, zĭ sū zĭ 9 g, dì lóng 15 g, xìng rén 12 g, kuăn dōng huā 9 g, chuān xiōng 9 g, and quán xiē 4.5 g. She had her second visit on August 13th, and reported that her asthma was immediately relieved after taking the prescription. She normally had one or two onsets per month, but the frequency dropped. Taking the above prescription could seize the onset. Activity would cause wheezing, profuse sweating, and poor appetite. The second treatment was to treat the root by supplementing the kidney,

improving qi reception, boosting the lung, dissolving phlegm, and relieving panting. Six doses of shú dì huáng 9 g, wŭ wèi zĭ 4.5 g, dōng chóng xià căo 9 g, zĭ hé chē 4.5 g, gān căo 4.5 g, chén xiāng 1 g (infused), zĭ sū zĭ 4.5 g, chuān bèi mŭ 3 g, dăng shēn 4.5 g, mài dōng 3 g, and duàn mŭ lì 12 g were prescribed. She had the third visit on September 6th, 1977. The patient said that she used the two above formulas. The first formula was used at the onset of an asthma attack, and the second formula was for the remission stage. She had been alternating the two formulas for several years up to date (sometimes interrupted or taken every other day), during which time her asthma has been controlled. She now has only little coughing and phlegm, slight wheezing with activity, and can participate in normal activities without a severe onset. She was advised to take the pill form of the second formula at doubled the dosage in order to enhance the effect. 1 1 Du Lian-tang, Tian De-lu, Hou Li-na. Dong Jian-hua’s Medical Cases 董建华医案选. Restricted Data of Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; 1978. p. 27.

Comments: Stagnant phlegm and water retention are the major causes of an asthma attack, yet doctors often overlook it. This case had a good effect because the pattern differentiation and treatment strategy matched. The acute onset stage belonged to the type of asthma caused by a pattern of lung cold with isolated heat. Diffusing the lung and clearing heat treated it. Dìng Chuăn Tāng without gān căo, sāng bái pí, and bàn xià was used as the base formula. Dì lóng, chuān xiōng, and quán xiē were added to relax spasms and relieve panting. The entire formula could clear the lung, direct qi downward, dissolve phlegm, and expel chronic retention. It was used during asthmatic episodes. During the remission stages, shú dì huáng, wŭ wèi zĭ, zĭ hé chē, and dōng chóng xià căo were used to supplement the kidney and improve qi reception. Dăng shēn, mài dōng, chuān bèi mŭ, zĭ sū zĭ, chén xiāng, and gān căo were used to boost the lung, move qi, and dissolve

phlegm. Mŭ lì was used to astringe the sweating in order to focus on the root. The formulas were alternated according to her condition, which allowed the function of her lung and kidney to recover.

Xiăo Bàn Xià Tāng ⼩半夏汤Minor Pinellia Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications Xiăo Bàn Xià Tāng is indicated for vomiting due to phlegm-rheum. The symptoms are vomiting phlegm-drool, lack of thirst, retching, hiccup, indigestion, and normal urination. The coating is white and glossy.

Analysis of Fundamental Pattern Pathogenesis This pattern is due to phlegm-rheum lodged below the heart and rising counterflow stomach qi. Phlegm-rheum stays in the stomach, the stomach qi cannot descend so it rises to cause vomiting. Vomiting damages body fluids and leads to thirst. Thirst indicates the pooled water is relieved after vomiting. However, in this situation, there is a lack of thirst after vomiting because the thoracic rheum still stays lodged below the heart. The treatment

is to dissolve phlegm, dissipate rheum, harmonize the stomach, and direct counterflow downward.

Formula Actions Dissolves phlegm, dissipates rheum, harmonizes the stomach, and directs counterflow downward.

Formula Analysis

Unique Combination Features Bàn xià and shēng jiāng mutually assistant one another to dissolve phlegm and harmonize the stomach. These two medicinals share mutual suppression (xiāng shā, 相杀) and mutual restraint (xiāng wèi, 相畏) to control toxicity.

Formula Applications 1. Essential pattern differentiation Xiăo Bàn Xià Tāng is a fundamental formula used to treat vomiting due to phlegm-rheum. This clinical pattern is marked by:

● vomiting with fever and no thirst

● white and glossy tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of vomiting due to phlegm-rheum: gastritis, gastrointestinal reaction due to inner ear disease, vertigo, and illeffects from chemotherapy. 4. Cautions and contraindications This formula is warm and drying, so it is not applicable for patients with vomiting due to patterns of wind-heat or yin deficiency with internal heat.

Associated Formulas Dà Bàn Xià Tāng ( Major Pinellia Decoction, ⼤半夏汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Mix honey with 1 dou and 2 sheng water and stir 240 times. Cook down to 2.5 sheng, take 1 sheng warm and leave the rest for later use.

[Actions] Harmonizes the stomach and directs counterflow downward, boosts qi and moistens dryness. [Applicable Patterns] Vomiting due to phlegm-rheum caused by qi deficiency. Symptoms include: regurgitation, evening vomiting of food eaten in the morning, or morning vomiting of food eaten in the evening, retained undigested food, spasm after vomiting, fatigue, a pale complexion, weak limbs, dry stools the size of goat pellets, a light red tongue with scanty coating, and a thready and weak pulse. Dà Bàn Xià Tāng and Xiăo Bàn Xià Tāng both contain bàn xià and both harmonize the stomach and direct counterflow downward. They are used for vomiting due to rising counterflow of stomach qi. Xiăo Bàn Xià Tāng uses the compatibility of bàn xià and shēng jiāng. Its focus is on harmonizing the stomach and directing counterflow stomach qi downward. It primarily dispels the pathogen. It is suitable for vomiting due to phlegm-rheum lodged under the heart and rising stomach qi counterflow. Dà Bàn Xià Tāng has only bàn xià to harmonize the stomach and direct rising counterflow stomach qi downward. Combined with rén shēn it boosts qi and supplements deficiency. The mix of honey and water has the effect to boost the stomach and promote fluid production in order to simultaneously eliminate the pathogen and strengthen the vital qi. It is suitable for vomiting due to spleenstomach weakness and body fluid insufficiency. Choose the correct formula according to individual case differentiation.

Case Studies 1. Vomiting, vertigo and dizziness (vertigo in inner ear)

Ms. Wang, a 55-year-old female, had her initial visit on May 10th, 1963. She had vertigo and dizziness for three days with frequent vomiting of profuse clear saliva. When she closed her eyes and lay down on her bed, she felt like she was spinning. She experienced these symptoms several times per year, and the longest episode could last for more than a month. It caused her a lot of suffering. Her condition was diagnosed as inner ear vertigo. Examination found her overweight. Her tongue coating was thin, white, and greasy. Her pulse was deep, soft, and slippery. She had a condition of fluid retention in the stomach that rebelled upward to disturb the clear heaven. The treatment method was to harmonize the stomach, dissolve rheum, direct counterflow downward, and remove turbidity. She was prescribed two doses of Xiăo Bàn Xià Tāng: bàn xià (processed) 12 g and shēng jiāng 10 g. She had her second visit on May 13th. She reported that the vertigo, dizziness, and vomiting all stopped. Fú líng 12g was added to the former prescription for two more doses. She was also prescribed Èr Chén Tāng with bái zhú and ginger juice in pill form for long term use in order to boost the effect. There were further episodes for two years according to her follow-up visit.1 Comments: The vertigo, dizziness, and vomiting in this case were caused by fluid retained in the stomach and turbid pathogen rebelling upwards to disturb the clear heaven above. The fluid retained in the stomach is the root, while the vomiting and vertigo are the branches. Therefore, Xiăo Bàn Xià Tāng was prescribed to harmonize the stomach, dissolve rheum, direct counterflow downward, and remove turbidity. The two medicinals were combined to resolve fluid retention and descend the turbidity. Xiăo Bàn Xià Tāng has an incredible effect of stopping vomiting. Two doses of the prescription worked to alleviate all of her symptoms. Fú líng was then added and the pill form of modified Èr Chén Tāng was used to fortify the spleen

and dissolve phlegm in order to treat the root of phlegm production and boost the treatment effect. 2. Bronchitis 1 Chen Ming. Successful Medical Cases from Famous Practitioner of Essentials from the Golden Cabinet⾦匮名医验案精选. Beijing: Academy Press; 1999. p. 37.

Li, a 5-year-old boy, had his initial visit on July 1978. This boy had bronchitis right after birth. He was hospitalized from 1-4 years old in a TCM hospital in Beijing because he was consistently ill and had a weak body constitution. He would often run a fever, contract the common cold, and cough repeatedly. This visit was because the patient had been coughing for more than one year with frequent onset. He had clear, loose phlegm that produces a rattling phlegm sound during sleep. He had a poor appetite, withered-yellow complexion, thin body, a pale tongue body, and a white, glossy, and greasy tongue coating. His hands were cold to the touch. This was a case of simultaneous illness of the hand and foot taiyin organs. Chronic water retention disturbed upward to the lung to cause chronic cough. The treatment was to warm and dissolve fluid retention, direct counterflow downward, and relieve cough. Xiăo Bàn Xià Tāng with additions was prescribed: fă bàn xià 10 g, shēng jiāng 10 g, fú líng 12 g, zĭ wăn 6 g, kuăn dōng huā 3 g, and gān căo 3 g. At his second visit, after taking two doses of the above formula, the cough reduced and the rattling phlegm sound reduced. However, he still had the cough with clear loose phlegm. So he was prescribed a modification of the above formula composed of: fă bàn xià 10 g, gān jiāng 6 g, fú líng 12 g, and gān căo 6 g. Thereafter, he then had no further onsets during the year up to his one year follow-up visit. 1 Comments: The boy had phlegm and cough related to illness of the hand and foot taiyin lung and spleen channels and organs. Modified Xiăo

Bàn Xià Tāng was prescribed because of the lodged fluid retention. It was used to warm and dissolve fluid retention, direct counterflow downward, and relieve cough. Zĭ wăn and kuăn dōng huā was used to more strongly resolve phlegm and stop cough. Fú líng and gān căo were used to fortify the spleen and dissolve phlegm. His second visit revealed that the cough and phlegm had both reduced. Therefore, zĭ wăn and kuăn dōng huā were removed and shēng jiāng was changed to gān jiāng in order to better warm the lung and resolve fluid retention. The case had been treated as a taiyin pattern of phlegm and cough. The patient was cured in only two treatments.

Xuán Fù Dài Zhĕ Tāng 旋覆代赭汤Inula and Hematite Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Decoct the medicinals in 1 dou water down to 6 sheng, strain the residues and boil, once again, down to 3 sheng. Take 1 sheng, warm(ed), three times a day. (Modern use: Prepare it as a decoction.)

Formula Indications Xuán Fù Dài Zhĕ Tāng is indicated for weak stomach qi with internal obstruction of phlegmturbidity. The symptoms are pĭ below the heart, belching, or vomiting with saliva. The tongue is pale with a white, glossy coating. The pulse is wiry and weak.

Analysis of Fundamental Pattern Pathogenesis

1 He Ren, Zhang Zhi-min, Lian Jian-wei. Hundred Doctor’s Cases Review of the Golden Cabinet ⾦匮⽅百家医案评议. Hangzhou: Zhejiang Science and Technology Press; 1991. p. 219.

The Treatise on Cold Damage explained that in cold induced disease, after sweating or vomiting and purgation is used to relieve the exterior, there may be pĭ below the heart with belching. This is because although the external pathogen has been resolved following sweating, vomiting, or purgation, the center qi has been injured. Interiorly generated phlegm and turbidity blocks the middle jiao causing the stomach qi counterflow upwards. The turbid phlegm obstructing the middle jiao causes qi blockage and pĭ below the heart that is not painful when palpated. The ascending counterflow of stomach qi causes frequent belching, vomiting, and hiccups. The characteristic of this formula pattern is middle jiao deficiency with phlegm obstruction. The treatment is to descend the rising stomach qi. Therefore, the strategy is to direct counterflow downward and dissolve phlegm while boosting qi and supplementing deficiency.

Formula Actions Directs counterflow downward, dissolves phlegm, boosts qi, and harmonizes the stomach.

Formula Analysis

Unique Combination Features Directs counterflow downward, dispels phlegm, boosts qi, and harmonizes the stomach simultaneously. It treats the root and branch simultaneously. It suppresses upward qi counterflow, but does not damage the stomach. It supplements the middle jiao, but does not increase phlegm.

Formula Applications 1. Essential pattern differentiation Xuán Fù Dài Zhĕ Tāng is commonly indicated for the pattern characterized by middle jiao deficiency, phlegm blockage, and qi counterflow. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of a middle jiao deficiency with phlegm blockage and qi counterflow pattern: gastric neurosis, gastric dilatation, chronic gastritis, gastric ulcers, duodenal ulcers, Helicobacter incomplete obstruction, neurological hiccups, and diaphragm spasms. 4. Cautions and contraindications Dài zhĕ shí has a cold nature and tends to descend. Its heavy property can block the stomach. A small dosage should be applied for patients who have stomach deficiency.

Case Studies 1. Belching Mr. Gao, a 79-year-old male retired employee had his initial visit on February 10th, 1967.

He had epigastric oppression and fullness, frequent belching, difficult swallowing, vomiting phlegm, and dry stools. His tongue coating was thick white and his pulse is wiry, slippery and large. His pattern belonged to liver qi invading the stomach with contention between phlegm and qi causing blockage. The treatment used acrid and moist medicinals to open and descend, drain the liver, calm the stomach, suppress counterflow downward, and eliminate pĭ. He was prescribed a combination of Xuán Fù Dài Zhĕ Tāng and Èr Chén Tāng: xuán fù huā 9 g, dài zhĕ shí 6 g, qīng bàn xià 9 g, chén pí 4.5 g, fú líng 9 g, huŏ má rén 9 g, zhĭ qiào (dry-fried) 4.5 g, wă léng zĭ 9 g, mài yá (dry-fried) 6 g and shēng gān căo 3 g. The formula was prepared as a water decoction. He came for his second visit on February 15th. After he completed five doses, the belching reduced, but there was still a large amount of phlegm and dry stools. His tongue coating was thin and white, and the pulse was slippery and moderate. He was kept on the same formula. His third visit was on February 20th. After taking four doses, the retching had not recently occurred, the epigastrium was now comfortable, and the bowel movements were smooth. But, he still had sticky phlegm. His tongue and pulse were the same as before. He was prescribed the same formula with zhĭ qiào removed and dāng guī 9 g and pí pá yè 9 g added to be taken as a water decoction. All of his symptoms were relieved following six doses.1 1 Wang Yun-sheng, Zhang Ji-ren, Wei Yu-ying. Wu Shao-huai Medical Cases 吴少怀医案. Jinan: Shandong Science & Technology Press; 1983. p. 100.

Comments: This was a pattern of liver qi invading the stomach and contention between phlegm and qi. Dr. Wu noted that the pulse and syndrome did not reveal deficient stomach qi, yet the aged should not be purged if there is not an excess pathogen. He prescribed Xuán Fù Dài Zhĕ Tāng and Èr Chén Tāng with the cloying medicinals rén shēn and dà zăo

removed. Then he added the phlegmdispersing, hard mass-softening medicinal wă léng zĭ, the qi-moving and digestion-promoting medicinals zhĭ qiào and mài yá, and the intestine-moistening medicinal huŏ má rén that promotes bowel movement. He used acrid moist medicinals to open and descend, drain the liver, and calm the stomach; salty flavor medicinals to eliminate pĭ; and heavy property medicinals to suppress counterflow. The medicinals were chosen related to the pattern, so the disease was cured. 2. Hiccup Mr. Chen, a 67-year-old male inpatient, had his first treatment process on May 28th, 1979. The patient had a chronic disease and recently started to have hiccups. His body constitution was weak, he had a light red tongue with a yellow coating on the tongue root, and his pulse was wiry and powerful. The treatment was to direct counterflow downward, dissolve phlegm, boost qi, and harmonize the stomach. One dose of Xuán Fù Dài Zhĕ Tāng with modifications was prescribed. The formulas was composed of: xuán fù huā 10 g, dài zhĕ shí 15 g, bàn xià 10 g, dăng shēn 10 g, zhè bèi mŭ 10 g, guā lóu 10 g, yù jīn 10 g, zhĭ qiào 10 g, chén pí 10 g, fú líng 10 g, and gān căo 10 g. His second visit was on May 29th. The hiccups were not yet seized, he vomited clear fluid last night, and had phlegm-drool. Therefore, bàn xià 2 g, fú líng 5 g, and shā rén 8 g were added to the above formula. He was prescribed one dose. His third visit was on May 30th. His hiccups seized, and his extremities swelled. Yì yĭ rén 30g and shí yīng 20 g were added to the former formula and he was prescribed one dose. By his fourth visit on June 1st, all of his symptoms were alleviated and the swelling in his extremities disappeared. The hiccups never returned and

he was prescribed another three doses of the latest formula to enhance the treatment effect.1 Comments: This patient had a weak body constitution, spleen deficiency, internal turbid phlegm, and stomach qi rising counterflow. The treatment should direct counterflow downward, dissolve phlegm, boost qi, and harmonize the stomach. Xuán Fù Dài Zhĕ Tāng with fú líng, chén pí, yù jīn, zhĭ qiào, zhè bèi mŭ, and guā lóu added was nsed to fortify the spleen, rectify qi, and dissolve phlegm. The spleen was strengthened, the phlegm resolved, and the stomach qi harmonized; therefore, the belching seized. In only two doses, the main symptoms were relieved.

Jú Pí Zhú Rú Tāng 橘⽪⽵茹汤Tangerine Peel and Bamboo Shavings Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

1 Liu Xue-zhu. Limited View of Medical Works 医林锥指. Tianjin: Tianjin Science and Technology Press; 1984. p. 180.

Preparation and Administration Prepare it as a decoction.

Formula Indications Jú Pí Zhú Rú Tāng is indicated for hiccups due to stomach deficiency with heat. The symptoms are hiccups, belching, restlessness, shortness of breath, and thirst. The tongue is red and tender. The pulse is weak and rapid.

Analysis of Fundamental Pattern Pathogenesis

Hiccups are always caused by stomach qi failing to descend. However, it should be further differentiated into cold, heat, deficiency, and excess. This pattern is due to middle jiao injury caused by chronic disease, vomiting and diarrhea, or stomach deficiency with heat and qi counterflow. The tongue is red and tender, and the pulse is weak and rapid. Based on the pathogenesis of this pattern, counterflow qi should be lowered, heat should be cleared, and stomach deficiency should be supplemented. Therefore, the treatment should focus on directing counterflow downward, relieving hiccup, clearing heat, harmonizing the stomach, boosting qi, and supplementing the center.

Formula Actions Directs counterflow downward, relieves hiccup, boosts qi, and clears heat.

Formula Analysis

Unique Combination Features

This formula uses sweet, cold medicinals combined with acrid, warm medicinals to clear without cooling. This formula moves, descends, and supplements qi in order to move qi without injuring the zheng qi and to supplement without cloying.

Formula Applications 1. Essential pattern differentiation Jú Pí Zhú Rú Tāng is commonly indicated for hiccups due to stomach deficiency with heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a pattern of stomach deficiency with heat and counterflow qi: vomiting during pregnancy, incomplete pyloric obstruction, spasms of the diaphragm, and postoperative hiccup. 4. Cautions and contraindications

It is not applicable for hiccup or vomiting caused by excess heat or deficiency-cold.

Associated Formulas Dīng Xiāng Shì Dì Tāng (Clove and Persimmon Decoction, 丁⾹柿蒂 汤) [Source] Symptoms, Causes, Pulses, and Treatment (Zhèng Yīn Mài Zhì, 症因脉 治) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Directs counterflow downward and relieves hiccup, warms the center and boosts qi. [Applicable Patterns] Hiccup due to deficiency cold. Symptoms include: hiccups and pĭ and fullness in the chest and stomach cavity, a pale tongue with a white coating, and a deep and slow pulse.

Comparison & Contrast Xuán Fù Dài Zhĕ Tāng vs. Jú Pí Zhú Rú Tāng vs. Dīng Xiāng Shì Dì Tāng

Continued

Case Studies 1. Hiccup Ms. Yuan, a24-year-old female, had her initial visit on April 14th, 1971. The patient described that she started to have continuous hiccups after she sweat heavily following a brisk walk and drank room temperature water. She normally had stomach weakness and a poor appetite. The treatment should boost the stomach and direct counterflow qi downward. She was prescribed a modification of Jú Pí Zhú Rú Tāng composed of jú pí 9 g, zhú rú 12 g, dăng shēn 12 g, zhì gān căo 6 g, shēng jiāng 2 pieces, dà zăo 5 pieces, shì dì 6 g and dīng xiāng 4.5 g. The hiccups stopped after taking only one dose. 1 Comments: This patient had congenital stomach weakness and her stomach was damaged by a cold drink. Pathogenic cold obstructs the middle jiao and stomach qi then counterflows to cause hiccups. Jú Pí Zhú Rú Tāng,

modified by adding dīng xiāng and shì dì, was used to warm the center and direct counterflow qi downward. Although zhú rú is cold in nature, it was counter balanced by a large group of warm medicinals, which then expresses its function to direct qi downward and relieve hiccups. In whole, the formula can warm the stomach and dissipate cold, direct qi downward, and relieve hiccup. Therefore, only one dose led to a cure. The correct formula compatibility covers both the root and branch. In this case, the weakness of the stomach recovered and the rebellious stomach qi descended, so the hiccup stopped. 2. Vomiting due to stomach heat 1 He Ren, Zhang Zhi-min, Lian Jian-wei. Hundred Doctors’ Cases Review of Golden Cabinet ⾦ 匮⽅百家医案评议. Hangzhou: Zhejiang Science and Technology Press; 1991. p. 320.

Mr. Zhou, from Hongshan County, had been vomiting and rolling about in bed for three days. Any food and water intake would cause vomiting. No formulas could alleviate his symptoms. He had been diagnosed with a pattern of rising counterflow of stomach fire. Huáng lián 3 g and zĭ sū yè 9 g were prescribed as a decoction to be sipped slowly. With it, the vomiting stopped. Thereafter, huáng lián (dry-fried with ginger juice) was added into Jú Pí Zhú Rú Tāng. The patient was cured after three doses. First use bitter medicinals to descend the rising counterflow stomach fire. Then clear the stomach heat and direct counterflow qi downward. This method would not cause the separation of heat and cold. The former doctors all used formulas to warm the center or Wū Méi Wán-based prescriptions, which explains why they did not work. 1 Comments: This was a case of vomiting due to rising counterflow of stomach fire. Although the heat was not excessive, the former formulas were not suitable for this case because they all warmed the center; so they were not effective. However, Dr. Kang learned this method from Xue Shengbai’s

damp-heat disease protocol, which treats stomach heat via lung transportation using Lián Sū Yĭn (Coptis and Perilla Beverage, 连苏饮) to arrest vomiting. He then applied Jú Pí Zhú Rú Tāng in order to use the bitter flavored descending huáng lián. The formula clears the stomach, directs counterflow downward, boosts qi, and reinforces the center. Therefore, the patient was cured.

Summary Qi-rectifying formulas have the functions of regulating qi movement, directing qi downward and relieving panting, and directing counterflow downward. They are mainly applied to patterns of qi counterflow and qi stagnation. Fourteen chief formulas are included in this chapter, divided into two categories:

● qi-moving formulas ● qi-descending formulas 1. Qi-moving formulas Yuè Jú Wán is good at moving qi in order to resolve constraint. It treats the pattern of six constraints, with an emphasis on qi constraint. Chái Hú Shū Gān Săn is good at soothing the liver to resolve constraint and moving qi to relieve pain. It is suitable for liver constraint and qi stagnation with ribside pain, belching, and sighing. Jīn Líng Zĭ Săn is good at soothing the liver and discharging heat and invigorating blood to relieve pain. It is used for liver constraint transforming into fire with pain in chest, abdomen, and hypochondria. Zhĭ Shí Xiè Bái Guì Zhī Tāng and Bàn Xià Hòu Pò Tāng both can move qi and dispel phlegm. Zhĭ Shí Xiè Bái Guì Zhī Tāng is good at unblocking yang and softening hardness and treats chest bì due to chest yang insufficiency, phlegm obstruction, and excessive yin-cold. Bàn Xià Hòu Pò

Tāng can open constraint and direct counterflow downward and treat the plum-stone qi caused by emotional disorders and binding constraint of phlegm and qi. Tiān Tái Wū Yào Săn, Jú Hé Wán and Nuăn Gān Jiān all move qi, soothe the liver, and treat liver channel qi stagnation type of shàn qì. But Tiān Tái Wū Yào Săn is focused on moving qi and dissipating cold and is especially good at moving qi to relieve pain and treating excess patterns of congealing cold and qi stagnation type of small intestinal shàn qì. Jú Hé Wán is good at moving qi and invigorating blood and softening and dissipating hard masses. It has a strong effect on dissipating masses and treats cold-damp shàn qì due to interior cold-dampness in the liver channel and binding constraint of qi and blood in an excess pattern. Nuăn Gān Jiān warms and supplements the liver and kidney for treating the root, while moving qi and dissipating cold to therapeutically address the branch symptomology. It mainly treats liver-kidney insufficiency and congealed cold in the liver channel type of shàn qì pain, which is a deficient root with excessive branch type of pattern. Jiā Wèi Wū Yào Tāng moves qi, invigorates blood, regulates menstruation, and relieves pain. It treats the liver constraint and qi stagnation type of painful menstruation. 2. Qi-descending formulas 1 Hunan TCM Institute. Hunan Selected TCM Cases. Volume One 湖南中医医案选辑·第⼀集. Changsha: Hunan People’s Publishing House; 1960. p. 150.

Sū Zĭ Jiàng Qì Tāng and Dìng Chuăn Tāng are good at directing qi downward and dispelling phlegm to relieve coughing and panting. Furthermore, Sū Zĭ Jiàng Qì Tāng also warms the kidney and supplements deficiency and treats coughing and wheezing in a pattern of upper excess and lower deficiency. Dìng Chuăn Tāng diffuses the lung and clears heat to treat asthma due to phlegm-heat accumulation in the lung. Xiăo Bàn Xià Tāng is good at dissolving phlegm, dissipating rheum, harmonizing the stomach, and

directing counterflow downward in order to treat phlegmrheum retention below the heart and stomach qi that cannot descend because of phlegmrheum causing vomiting. Xuán Fù Dài Zhĕ Tāng and Jú Pí Zhú Rú Tāng descend counterflow qi, relieve vomiting and hiccups, and have the function to supplement qi and boost the stomach. Therefore, they can stop belching and hiccups due to rebellious middle jiao qi. However, Xuán Fù Dài Zhĕ Tāng is good at dispelling phlegm and relieving belching. It is suitable for epigastric oppression, belching, regurgitation, and vomiting due to middle jiao deficiency with phlegm obstruction and stomach qi counterflow. Jú Pí Zhú Rú Tāng is good at relieving hiccups and treating vomiting and retching caused by stomach heat and deficiency.

Questions 1.Which zang-fu organs are related to the indications of qi-moving formulas and qi-descending formulas? What should be noticed regarding the compatibility of formulations? 2.Yuè Jú Wán treats qi, blood, phlegm, fire, dampness, and food stagnation. But why is there no phlegmdispelling medicinals in this formula? 3.What is the major pattern treated by Tiān Tái Wū Yào Săn? Why remove bā dòu and keep chuān liàn zĭ after they have been stir-fried together? 4. Guā Lóu Xiè Bái Bái Jiŭ Tāng, Guā Lóu Xiè Bái Bàn Xià Tāng, and Zhĭ Shí Xiè Bái Guì Zhī Tāng all treat chest bì. How are they differentiated for use in practice? 5.What is the compatibility of bàn xià with hòu pò in Bàn Xià Hòu Pò Tāng and Sū Zĭ Jiàng Qì Tāng? Please give an explanation according to each formula’s pattern and pathogenesis.

6.Both Sū Zĭ Jiàng Qì Tāng and Dìng Chuăn Tāng can direct counterflow downward, dissolve phlegm, and relieve panting. What are the differences in their indications and formulation strategies? 7.What is the analysis for the dosage of xuán fù huā and dài zhĕ shí in Xuán Fù Dài Zhĕ Tāng? 8. Xuán Fù Dài Zhĕ Tāng, Jú Pí Zhú Rú Tāng, and Dīng Xiāng Shì Dì Tāng all have the function to boost the stomach and direct counterflow downward. How are they differentiated for clinical practice?

Endnotes: [1] 厥阴之脉络阴器 [2] 任脉为病，男⼦内结七疝 [3] 诸疝皆归肝经 [4] 按痛则不通，通则不痛 [5] 经前腹胀痛，乃⾎⽓凝滞，若胀过于痛，是⽓滞其⾎也，宜⽤ 加味乌药汤开之

CHAPTER 11 Blood-Regulating Formulas Blood-regulating formulas utilize blood-regulating medicinals as key components. They have the therapeutic actions to invigorate blood and dissolve stasis. Blood-regulating formulas are prescribed to treat blood stasis or bleeding. Blood is an essential nutrient to the human body. Normally, circulating in arteries and veins, blood irrigates the zang-fu organs and cultivates the four limbs and the skeleton. Blood stasis, bleeding, or blood deficiency may result if there is a pathological condition that leads to poor blood flow or has caused an obstruction, if the blood fails to stay in the channels, or if there is blood deficiency. The treatment for blood stasis is to invigorate blood and dissolve stasis. The treatment for bleeding is to stanch bleeding. The treatment for blood deficiency is to supplement the blood. Moreover, bloodsupplementing formulas have been discussed in Chapter 7 Supplementing and Boosting Formulas. In this chapter, the prescriptions are divided into two types according to different therapeutic therapies:

● formulas that invigorate blood and dissolve stasis ● formulas that stanch bleeding When formulas that regulate the blood are applied, it is important to detect the cause of the blood stasis or bleeding and distinguish whether it is associated with the root cause or a symptom. It is also important to

determine if it is an acute or chronic case in order to treat the root cause when it is acute or treat the symptoms when it is chronic; or treat both the root cause and the symptoms simultaneously. It is best to avoid dissolving blood stasis or stanching bleeding blindly. In addition, one must keep in mind that strong elimination of blood stasis or long-term administration of stasisdissolving medicinals may damage the blood or zheng qi. In these cases, blood-nourishing and qitonifying medicinals should be added in order to prevent the damage of zheng qi while dissolving stasis. Expelling stasis is a drastic method that can be used only for a short time until the pattern is resolved. Stanching bleeding can lead to retention of blood stasis, so a small amount of bloodinvigorating and stasis-dissolving medicinals may be added to formulas that stanch bleeding or one can select hemostatic medicinals associated with the effects of invigorating blood and dissolving stasis in order to prevent blood retention while stanching bleeding. Dissolving stasis should be the first step when treating bleeding due to obstruction by blood stasis or blood leaving the vessels, because bleeding cannot be stopped without the blood stasis being removed. Though bloodinvigorating and stasis-dissolving formulas can promote blood circulation, they are drastic in property and easily induce bleeding and cause abortions. Therefore, they should be used cautiously for patients with menorrhagia and for pregnant women.

Section 1 Formulas that Invigorate Blood and Dissolve Stasis Formulas that invigorate blood and dissolve stasis are used to treat all sorts of diseases and syndromes caused by blood stasis. Examples include:

● lower jiao blood amassment syndrome due to binding of stasis and heat

● chest and abdomen pain due to retention of blood stasis ● hemiplegia due to stasis obstruction of the channels ● menstrual block ● painful menstruation or inhibited lochia ● masses caused by stasis amassment ● traumatic bruising and swelling ● carbuncles in the early stage Blood-invigorating and stasis-dissolving medicinals like chuān xiōng, táo rén, hóng huā, chì sháo, and dān shēn are commonly used in these formulas. Since qi is the commander of blood and its circulation promotes blood flow, qi-regulating medicinals are often added to a formula to strengthen its effect to invigorate blood and dissolve stasis. In addition, one may add medicinals that address the nature of the disease in terms of being hot or cold, and deficient or excessive. Blood circulation can be increased by warmth, so add medicinals that warm the channels and dissipate cold in order to improve blood circulation in a cold pattern. In patterns of blood stasis in the lower jiao with heat, add medicinals that drain and discharge heat. They can make a path through which the pathogen can be eliminated by draining blood stasis downwards. Add medicinals that boost qi and supplement blood to treat stasis with deficiency in order to prevent the damage of qi. When treating pregnant women, only use small dosages of medicinals that will slowly dissolve stasis in order to protect the fetus. Frequently used formulas are Táo Hé Chéng Qì Tāng, Xuè Fŭ Zhú Yū Tāng,

Fù Yuán Huó Xuè Tāng, Bŭ Yáng Huán Wŭ Tāng, Wēn Jīng Tāng, Shēng Huà Tāng, and Guì Zhī Fú Líng Wán.

Táo Hé Chéng Qì Tāng 桃核承⽓汤Peach Kernel Qi-Guiding Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Decoct the first four medicinals with water. Take the decoction after mixing in the máng xiāo.

Formula Indications Táo Hé Chéng Qì Tāng is indicated for patterns of blood amassment in the lower jiao. The symptoms are distension and spasmodic pain in the lower abdomen, normal urination, fever at night, menstrual block due to blood stasis, and painful menstruation; there may even be delirium, dysphoria, and mania. The pulse will be deep and excessive or choppy.

Analysis of Fundamental Pattern Pathogenesis This formula is used to treat blood retention in the lower jiao caused by an unresolved taiyang pattern that travels along the taiyang channel and enters the taiyang fu-organ, which then transforms into heat and finally binds with blood. The binding of stasis and heat in the lower jiao leads to distension and spasmodic pain in the lower abdomen. The location of this disease is in the blood level instead of the qi level. Therefore there is no effect on the bladder qi transformation thus leaving the urination normal while there is fever during night. The heart governs the blood vessels and stores the spirit, which is disturbed by rising heat caused by stasis. As a result, there may be vexation, agitation, delirium, dysphoria, and mania. This is a pattern of binding stasis and heat. Therefore, the therapeutic principle is to break up and expel blood stasis through purgation in order to eliminate the blood retention from the lower jiao.

Formula Actions Breaks up blood and expels stasis through purgation.

Formula Analysis

Unique Combination Features This formula has the features of cooling with warming, clearing with converting, purging with breaking, treating both stasis and heat. It is better to result in slight diarrhea, which provides a way out for pathogens.

Formula Applications 1. Essential pattern differentiation Táo Hé Chéng Qì Tāng is commonly used to treat blood amassment in the lower jiao due to binding of blood stasis and heat. This clinical pattern is marked by:

● distension and spasmodic pain in lower abdomen ● normal urination

● deep, excessive or choppy pulse 2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders, when the patient shows signs of binding of stasis and heat in the lower jiao: acute pelvic inflammatory disease, retained placenta, annex inflammation, intestinal obstruction, and endometriosis. 4. Cautions and contraindications If the patient has an unresolved exterior syndrome, first release the exterior pattern and thereafter use this formula to eliminate stasis. Táo Hé Chéng Qì Tāng is not applicable for pregnant women because of its drastic effect in breaking up blood and expelling stasis through purgation.

Case Studies 1. Lower jiao blood amassment syndrome

A man in his twenties, accompanied by his father, contracted an exterior pattern. Other doctors, using a variety of therapeutic methods, caused him to experience frequent changes in his condition. He was observed to have a yellowish complexion, abdominal distention, without fever or chills. He would scowl at others whenever they sat down quickly, ready to attack with clenched fists. All of his symptoms would last for only a short period of time, and then he would return to his normal behavior. His pulse was deep and choppy, and his tongue was yellow and dusky with bright red on the bottom. His father urged the doctor to prescribe a formula and asked about the cause of the disease. The doctor answered that the disease had progressed into the blood level, and the previous doctors prescribed medicinals that could only reach the qi level. That is why he was not cured. The Yellow Emperor’s Inner Classics said, “blood stasis in the upper body causes forgetfulness, and in the lower part causes mania.”[1] The Treatise on Cold Damage states, “heat accumulation in bladder cause mania.”[2] The correct formula to apply was Táo Hé Chéng Qì Tāng. All of his symptoms were reduced after taking one dose, and the symptoms fully cleared after two doses. Thereafter, Xiāo Yáo Săn with added mŭ dān pí, zhī zĭ, and shēng dì was used to regulate his condition further.1 Comments: The key to differentiate this syndrome as blood amassment was distension and fullness of lower abdomen, deep and choppy pulse, dark yellow tongue coating and bright red body. The pattern belonged to stasis heat in the blood level, so changing the previous prescription into Táo Hé Chéng Qì Tāng to dispel stasis and drain heat achieved an obvious therapeutic effect after only two dosages. 2. Bloody stool 1 Liu Bing-fan, Zhou Shao-ming. Essence of Ancient Books and Records of Famous Doctors in Hunan Province (Volume of Internal Medicine) 湖湘名医典籍精华（内科卷）. Changsha: Hunan

Science and Technology Press; 1999.

Sun Wen-yuan treated Dong Long-shan’s wife. She was 35 years old and suffered from bloody stools two or three times a day without abdominal pain. She had been treated for three years without efficacious results before seeing Dr. Sun. Her left pulse was deep and choppy and her right pulse deviated at the guān, which was a pulse pattern that did not match her symptoms. The doctor explained that since there was long-term bleeding, it was necessary to tonify the qi in order to generate blood. According to the differentiations made following the four diagnostic methods, he prescribed Bŭ Zhōng Yì Qì Tāng with added ē jiāo, dì yú, and cè băi yè. After taking eight doses, no more blood appeared in the stool for half a month. However, when she worked too much, blood would occasionally appear in the stool. Whenever that happened, she would ask for that same prescription. The doctor rationalized that there must be some blood stasis accumulated in the channels. He therefore prescribed medicinals that rise and supplement, as well as, those that are astringent in order to explore whether the disease was of a deficient or excessive nature. After figuring out the nature of the condition, purgation was used to treat it. Mr. Dong asked if there might be blood stasis retention considering that she had bloody stools for three years, two to three times per day along with abnormal menstruation that would last four to five days. The answer was that it was the the reason that she was known to have blood stasis retention. The classic book stated, “healthy stream cannot flow regularly before stasis is removed.”[3] This is why ancient people treated diarrhea by first using the purgative method. She was prescribed Táo Hé Chéng Qì Tāng with added mŭ dān pí, wŭ líng zhī, and hé yè dì. It was decocted with water and taken orally at night. After taking it she excreted half a barrel of black stasis. The patient asked to be given the purgatives again. But it was explained that since the root of the

disease has been moved, she needed to have spleen-supplementing medicinals at that point instead. It’s never too late to use purgatives. As a result, black stasis was excreted. Afterwards, use Bŭ Zhōng Yì Qì Tāng and Shēn Líng Bái Zhú Săn was prescribed in order to help her recover.1 Comments: The patient had bloody stools for three years, and had not received an effective treatment from her previous doctors. Dr. Sun first considered it to be a deficiency pattern with stasis. But then he reconsidered and decided to follow the principle stated in classic book that healthy stream cannot flow regularly before stasis has been removed. Therefore, he then prescribed Táo Hé Chéng Qì Tāng to purge blood stasis. He added mŭ dān pí and wŭ líng zhī to strengthen, and hé yè dì to stop bleeding by raising yang. She took the decoction at night, when shaoyang is active and can prevent medicinal rejection (this was a method of paradoxical assistance). He stopped the purging as soon as the stasis was gone instead of purging for a long time, which may treat the disease but at the expense of the patient’s health. Then Bŭ Zhōng Yì Qì Tāng and Shēn Líng Bái Zhú Săn were used to supplement the spleen qi and raise the clear yang for a full recuperation.

Xuè Fŭ Zhú Yū Tāng ⾎府逐瘀汤Blood Mansion Stasis-Expelling Decoction Source Text Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错) 1 Wei Zhi-xiu. Supplement to ‘Classified Case Records of Famous Physicians’ Vol. 12 续名医类 案·卷12. Beijing: People’s Medical Publishing House; 2000.

Formula Ingredients

Preparation and Administration Prepare it as a decoction.

Formula Indications

Xuè Fŭ Zhú Yū Tāng is indicated for blood stasis in the chest. Symptoms include: chest pain, headache, and chronic stabbing pain at a fixed location, continual hiccups or choking when drinking water, nausea, internal heat, dizziness, severe palpitations, insomnia, dreaminess, impatience, irascibility, tidal fever at night, dark lips or eyes, a dark red tongue with ecchymosis or purple spots, and a choppy or wiry, tight pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by qi that becomes stagnant due to obstructive blood stasis. Particularly, it is blood stasis in the chest, which is the house of the blood. The chest is where qi roots and blood accumulates, and an area coursed by the liver channel. Long-term chest pain and headaches with stabbing pain at a fixed location are caused by blood stasis in the chest, qi stagnation, and clear yang failing to ascend. Obstruction in the chest caused by blood stagnation may involve the stomach and cause stomach qi to counter-flow ascend. The result is hiccups, belching, and even choking when drinking water. Long-term stasis transforms into heat, which causes internal heat, dizziness, and tidal fever at night. Stasis heat disturbing the heart causes severe palpitations, insomnia, and dreaminess. Enduring qi stagnation hinders the liver’s capacity for free flow, which leads to impatience and irascibility. The manifestations at the lips, eyes, tongue, and pulse reflect symptoms of blood stasis. The therapeutic method is to invigorate blood, dissolve stasis, and move qi to relieve pain.

Formula Actions Invigorates blood, dissolves stasis, and moves qi to relieve pain.

Formula Analysis

Unique Combination Features First, invigorating the blood while also moving the qi can remove stasis in the blood level as well as resolve stagnation in the qi level. Second, dispelling stasis combined with nourishing blood can invigorate blood without consuming blood, as well as, move qi without damaging yin. Third, the combination of both ascending and descending can not only lift and free clear yang, but also purge downward to harmonize qi and blood. The prescription as a whole has the effect to activate blood, remove stasis, and

circulate qi in order to address all symptoms. This is an effective prescription to treat blood stasis in the chest.

Formula Applications 1. Essential pattern differentiation Xuè Fŭ Zhú Yū Tāng is commonly used in many diseases caused by blood stasis in the chest. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is commonly used in biomedically-defined disorders such as coronary heart disease, rheumatic heart disease, chest contusion, rib cartilage inflammation with chest pain, cerebral thrombosis, hypertension, hyperlipidemia, thromboangiitis obliterans, neurosis, sequelae of cerebral concussion, headache, and dizziness when the patient shows signs and symptoms of blood stasis and qi stagnation.

4. Cautions and contraindications This formula mainly contains blood-invigorating, stasis-dissolving, qimoving, and collaterals-unblocking medicinals. Consequently, it is not applicable for neither pregnant women nor the sick and elderly.

Associated Formulas Tōng Qiào Huó Xuè Tāng (Orifices-Unblocking and BloodInvigorating Decoction, 通窍活⾎汤) [Source] Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错) [Ingredients]

[Preparation and Administration] Decoct the first seven medicinals with water down to one bowl and remove the dregs. Then mix the shè xiāng to the wine, add it to the decoction, reheat the decoction and bring it to a boil two more times. Take it orally before sleeping. [Actions] Invigorates blood and unblocks the orifices. [Applicable Patterns] Obstructive stasis in the head and face. Symptoms include: headache and vertigo, deafness, blue-purple complexion, rosacea, leucoderma, dried

blood consumption of women, infantile malnutrition and accumulation with emaciation, enlarged abdomen with varicose veins, tidal fever, etc. Gé Xià Zhú Yū Tāng (Expelling Stasis Below the Diaphragm Decoction, 膈下逐瘀汤) [Source] Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Invigorates blood and dissolves stasis, and moves qi to relieve pain. [Applicable Patterns] Stasis obstruction under the diaphragm. Symptoms include: masses or abdominal lumps in children, fixed pain in the abdomen, or a falling sensation when lying down. Shào Fù Zhú Yū Tāng (Lower Abdominal Stasis-Expelling Decoction, 少腹逐瘀汤) [Source] Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错)

[Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Invigorates blood and dissolves stasis, and warms the channels and relieve pain. [Applicable Patterns] Blood stasis in the lower abdomen. Symptoms include: painful or painless masses, or pain without masses, distention and fullness in the lower abdomen, sore waist during period, or menstruation that occurs three or five times a month, continuously or intermittently, the color is purple or black, sometimes with blood clots, or flooding and spotting accompanied with lower abdominal pain. Shēn Tòng Zhú Yū Tāng (Generalized Pain Stasis-Expelling Decoction, 身痛逐瘀汤) [Source] Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Invigorates blood and moves qi, dissolves stasis and unblocks the channels, and unblocks bì to relieve pain. [Applicable Patterns] Qi and blood obstruction in channels and collaterals. Symptoms include: pain of the shoulders, arms, waist, and legs, or all over the body. Xuè Fŭ Zhú Yū Tāng, Tōng Qiào Huó Xuè Tāng, Gé Xià Zhú Yū Tāng, Shào Fù Zhú Yū Tāng, and Shēn Tòng Zhú Yū Tāng are all highly effective formulas created by Wang qing-ren that invigorate blood and dissolve stasis. Collectively, they are referred to as the five stasis-expelling formulas. Each of them consists of similar fundamental medicinals like táo rén, hóng huā, chuān xiōng, chì sháo, and dāng guī and have the function to invigorate blood, dissolve stasis, and relieve pain in order to treat syndromes caused by blood stasis. Each of the five formulas also has their particular function and specific medicinals. In Xuè Fŭ Zhú Yū Tāng, zhĭ qiào, jié gĕng, and chái hú can move qi and loosen the chest, and niú xī can direct blood downward. This formula has a good effect to disperse qi stagnation from the chest and guide the blood to move downward. It is therefore the major formula used to treat stasis obstruction in the chest. In Tōng Qiào Huó Xuè Tāng, shè xiāng and lăo cōng can unblock yang and open the orifices, therefore it is good to

activate the blood and open the orifices, which treats stasis obstruction in the head. In Gé Xià Zhú Yū Tāng, liversoothing and qi-regulating medicinals xiāng fù, wū yào, and zhĭ qiào have a strong effect to move qi and relieve pain. It is mainly used for blood stasis that has accumulated under the diaphragm with distending pain in the abdomen with masses, and pain in the hypochondrium due to liver qi stagnation. In Shào Fù Zhú Yū Tāng, xiăo huí xiāng, ròu guì, and gān jiāng can warm the body in order to move qi, thereby it has a strong effect to warm the channels and relieve pain. It treats lower abdominal masses, irregular menses, and painful menstruation due to blood stasis. Shēn Tòng Zhú Yū Tāng contains qín jiāo, qiāng huó, and dì lóng, which can diffuse bì and unblock the collaterals. It is commonly used for bì syndrome of the four limbs and painful joints.

Case Studies 1. Vertigo Han was a 32-year-old female. A year ago, starting from mental stimulation, she fell into low spirits. In the beginning she felt that she was spinning around, but later she could not stand still. Later, she felt that the general scenery was constantly rotating, sometimes her ears felt blocked, but without tinnitus. She did not have any nausea or vomiting. Her body felt entwined by spider silk and her head felt tight as if it was wrapped up. She also had palpitations and forgetfulness. Her menstruation was basically normal with a moderate amount of purple-red blood clots. In another hospital the results of a cerebral blood flow examination and electrocardiogram were normal. Therefore it was suspected that she suffered with psychoneurosis. She had a wiry, thin and choppy pulse, a light red tongue body with ecchymosis, and the coating was thin and white. The pattern was caused by emotional disorder, blood stasis, qi stagnation, spirit

obstruction, and apraxia. Five doses of modified Xuè Fŭ Zhú Yū Tāng was prescribed, composed of chái hú 6g, chì sháo 12 g, zhĭ qiào 10 g, zhì gān căo 6 g, chuān xiōng 10 g, dāng guī 10 g, shēng dì 10 g, táo rén 10 g, hóng huā 6 g, jié gĕng 6 g, chuān niú xī 10 g, zhēn zhū mŭ 15 g, and cí shí 15 g (decocted first). On the second visit, the vertigo was reduced and the pulse and tongue improved, but she still felt entwined by spider silk and she still had the tight, wrapped head. Based on the original formula zhēn zhū mŭ and cí shí were removed, and băi hé 30 g and shēng dì 15 g were added. After taking three doses of the formula, all of the symptoms, including the vertigo, were alleviated. For the next half month, she was prescribed formulas based on the formula above, and she was finally cured. She was suggested to avoid vexation and anger, relax her mood, and regulate the spirit and all symptoms were eliminated with no reoccurrence reported over the past six months.1 Comments: In this case, the vertigo and dizziness were caused by blood stasis. Direct Pointing Formula said, “all stasis obstruction can lead to vertigo and dizziness.”[4] Qi deficiency, qi stagnation, qi counterflow, or traumatic injury can all cause blood stasis. This case is diagnosed as qi stagnation and blood stasis, Xuè Fŭ Zhú Yū Tāng is applied to invigorate blood, dissolve stasis, soothe the liver, and regulate qi. Zhēn zhū mŭ and cí shí, heavy sedatives, were added to calm the mind. Once the prescription started to help, a heavy dose of băi hé and shēng dì was added to nourish yin and calm the mind, combining spirit regulation for further recovery. 2. Intractable enuresis 1 Zhang De-chao. Treating Stasis for Vertigo 眩晕从瘀论治. Journal of Traditional Chinese Medicine. 1992; 33(9): 15-16.

Tan was a 17-year-old female. She had her first visit on May 14th, 1976. For eleven years she had enuresis, and she took a lot of qi-tonifying, spleenreinforcing, kidney-strengthening, and astringent prescriptions without any improvement. She had enuresis twice every night. It made her worried, depressed, vexed, and irascible; and she had a low-grade fever at night, dreaminess, and a dry month with no desire to drink. Each month she had three menstruations with premenstrual abdominal pain. The menstrual blood was scant in volume and purple in color. She had a lot of ecchymosis on the sclera, a purple red tongue with a thin, white coating, and her pulse was thready and wiry. Her pattern was differentiated as binding liver qi constraint caused by long-term blood stasis, the liver qi failed to circulate, the bladder failed to open and close, and the sanjiao failed to control the water channels, which therefore led to frequent enuresis. The treatment principle was to soothe the liver, regulate qi, invigorate blood, and dissolve stasis. She was prescribed twenty-one doses of chái hú 4.5 g, hóng huā 9 g, táo rén 12 g, chì sháo 18 g, niú xī 4.5 g, shēng dì 12 g, dāng guī 9 g, zhĭ qiào 4.5 g, jié gĕng 4.5 g, chuān xiōng 4.5 g, shēng má 4.5 g, bái jiăn ké 5 pieces, jiŭ cài zĭ 12 g, and gān căo 3 g. On her second visit, the enuresis disappeared while taking the prescription. Her period occurred two weeks ago with abdominal pain, and profuse purple blood with a lot of blood clots. Ecchymosis on the sclera lightened, the purple of the tongue body also lightened, and the pulse was thready and wiry. Since the principle of treating the liver worked, modified prescriptions based on the original formula above were given for three months and the enuresis never re-appeared. Guī Pí Tāng was used thereafter to improve her recovery. The therapeutic effect was proven excellent with no recorded re-occurrences over the past years. 1

Comments: During the past dynasties, TCM doctors often treated the kidney for enuresis. However, clinical practice has found that it is also closely related to the liver. The liver channel of foot jueyin curves around the external genitalia and goes up to the lower abdomen. The original text from The Spiritual Pivot-Channels said, “the liver channel of foot jueyin can treat diseases due to the disorder of liver such as enuresis and uroschesis.”[5] This is why Zhu Dan-xi said, “the kidney dominates stool while the liver controls urine.”[6] This case lasted for over ten years. Treating her enuresis for a long time with no effect lead to her depression, qi and blood stagnation, ecchymosis on the sclera, premenstrual abdominal pain, and purple blood clotted menses. Qi stagnation and blood stasis cannot be treated with formulas that supplement and astringe. Modified Xuè Fŭ Zhú Yū Tāng treated the liver by soothing the liver and dissolving stasis in order to free constrained qi and blood. Gradually the disease was cured.

Bŭ Yáng Huán Wŭ Tāng 补阳还五汤YangSupplementing and Five-Returning Decoction Source Text Correction of Errors in Medical Works (Yī Lín Găi Cuò, 医林改错)

Formula Ingredients

1 Clinical records of Yan De-xin, recorded by Dong Jian-hua. Modern Essential Clinic Records of Famous Chinese Doctors of TCM. Vol. 5. 中国现代名中医医案精华(五). Beijing: Beijing Publishing House; 1990.

Preparation and Administration Prepare Bŭ Yáng Huán Wŭ Tāng as a decoction.

Formula Indications Bŭ Yáng Huán Wŭ Tāng is indicated for wind-strike due to qi deficiency and blood stasis marked by hemiplegia, deviation of the mouth and eye, sluggish speech, involuntary salivation from the mouth, frequent urination or enuresis, a dark tongue body with a white coating, and a slow, weak pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is due to zheng qi deficiency, qi and blood stagnation, and obstructed blood vessels following wind-strike. Deficiency of zheng qi cannot move blood. This leads to the obstruction of the blood vessels, which then cannot nourish tendons and muscles. This causes hemiplegia and deviation of the mouth and eye. The original text from The Spiritual PivotNeedling said, “pathogens invade half of the body, then go deep inside, where yin and wei dwell, if there is even slight insufficiency of yin and wei, zheng qi will leave while the pathogen will stay, causing hemiplegia.”[7] Sluggish speech is due to qi deficiency and blood stasis failing to nourish the tongue. Involuntary salivation from the mouth and frequent urination or enuresis is caused by qi deficiency failing to control. A dark tongue with a white coating, and a slow, weak pulse reflect qi deficiency and blood stasis. The root of this pattern is qi deficiency while the branch is blood stasis, which has been explained by Wang qing-ren as “deficiency produces stasis”[8]. Therefore, the therapeutic method is to focus on supplementing the qi while invigorating the blood and unblocking the collaterals.

Formula Actions Supplements qi, invigorates blood, and unblocks the collaterals.

Formula Analysis

Unique Combination Features In this formula, a qi-reinforcing medicinal is used in a heavy dosage accompanied by small amounts of blood-invigorating medicinals. This combination reinforces qi and moves blood to treat the root of the disease, dispel stasis and unblocks the collaterals to treat the branch. This gives the advantage of supplementing qi without causing stagnation, and activating blood without damaging zheng qi. The prescription as a whole has the effect to supplement qi, remove stasis, unblock collaterals, and relieve all the related symptoms.

Formula Applications 1. Essential pattern differentiation Bŭ Yáng Huán Wŭ Tāng is the representative formula that reflects the therapeutic method of simultaneously reinforcing qi and circulating blood, and is commonly used to treat the sequela of stroke. This clinical pattern is marked by:

2. Modifications In this formula, huáng qí is used at a heavy dosage. It is best to start with a smaller dose (30-60 g), and then if it does not work well, increase the dosage gradually. The dosages of the blood-activating and stasis-expelling medicinals in the original formula are small, but they can be increased gradually according to the state of the disease being treated.

3. Modern Applications Bŭ Yáng Huán Wŭ Tāng is often used for the sequela of cerebrovascular accident, coronary heart disease, sequela of polio, hemiplegia, paraplegia, and unilateral flaccid paralysis of the limbs due to qi deficiency and blood stasis. 4. Cautions and contraindications

The therapeutic effect of this formula will emerge after long-term administration, and the patient should keep taking it even after their recovery in order to consolidate the effect and preventing recurrence. As Wang said, “the prescription should be continually taken even if the disease is cured, one dosage for every three to five, or seven to eight days.” This formula is not applicable for hemiplegia due to yin deficiency with hyperactive yang, phlegm obstruction, and blood stasis marked by a red tongue body, a yellow tongue coating, and a big, powerful pulse.

Case Studies Sequela of apoplexy Chen, a 78-year-old male, suffered from a twisted mouth, stiff tongue, and mobility problems of both his legs for over one year. The Western medication troxerutin did not work. Upon diagnosis it was observed that the corner of his mouth tilted towards the left, he was drooling, had a stiff tongue, and spoke with sluggish speech. His legs had tremors and no strength, he had difficulty in raising his legs, and unsteady gait. His consciousness was clear with slow reactions, dull thoughts, forgetfulness, and palpitations. His tongue was puffy with a thin, yellow, and greasy coating and it deviated to the left, and his pulse was wiry and stiff. His blood pressure was 150/90 mmHg. A CT scan showed encephalatrophy and lacunar infarction. The syndrome differentiation was phlegm and stasis obstructing the collaterals and orifices. The treatment method used was to boost qi, invigorate blood, dissolve stasis, and unblock the collaterals. Modifications of Bŭ Yáng Huán Wŭ Tāng and Dăo Tán Tāng were applied. The prescription was composed of dāng guī 10 g, chuān xiōng 10 g, shēng huáng qí 30 g, táo rén 10 g, chì sháo 12 g, hóng huā 8 g, zhì gān căo 6 g, zhì dì lóng 15 g, zhú rú 10 g, zhĭ shí 10 g, guā lóu pí 15 g, tiān zhú huáng 6 g,

zhì tiān nán xīng 6 g, and zhì bàn xià (processed) 8 g, together with Zhú Lì Shuĭ 20 ml×3 bottles (the patented drug of zhú lì). He was given eight dosages. He was advised to maintain a good mood, and eat a light diet avoiding oily and greasy foods. On his second visit his twisted mouth had largely adjusted, the tremors in his legs were alleviated, his motor abilities improved, and he could move freely with energy. Dān shēn 15 g and bĕi shā shēn 15 g were added to the original formula and he was given twenty dosages. On his third visit his twisted mouth was totally adjusted, he could speak fluently, and walk normally. Therefore he stopped taking the formulas. A follow-up visit at six months showed that the patient could speak and walk normally, he had a flushed complexion, and a normal spirit. Due to financial reasons he did not have a head CT scan re-examination.1 Comments: In this case the facial palsy, stiff tongue, and sluggish speech were due to wind, phlegm, and blood stasis blocking the house of the spirit. Wind and phlegm flowed into the channels and collaterals, which blocked the blood vessels. The channels and collaterals could not be nourished, which then lead to tremors, lack of strength, mobility problems, and unsteady gait. Therefore Bŭ Yáng Huán Wŭ Tāng was used to move qi, invigorate blood, and unblock the collaterals. A modified Dăo Tán Tāng was used to dispel wind, dissolve phlegm, and unblock the collaterals. Zhú lì was used to unblock the collaterals by clearing heat and dissolving phlegm. The combination of these two formulas shows an amazing effect to adjust the position and function of the mouth and recover the motor function of both legs. As The Yellow Emperor’s Inner Classic said, “if one formula didn’t work, we add another one to assist; which is essentially compounding formulas.”[9]

Fù Yuán Huó Xuè Tāng 复元活⾎汤Original QiRestoring and Blood-Moving Decoction Source Text Medical Invention (Yī Xué Fā Míng, 医学发明) 1 Clinical records from Zhang De-chao, recorded by Ni Cheng. Newly Organized Formulas of Chinese Medicine 新编⽅剂学. Beijing: People’s Medical Publishing House; 2006.

Formula Ingredients

Preparation and Administration Except for táo rén, chop the rest of the medicinals as small as beans. Then decoct 1 liang with 1.5 cups of water and 0.5 cup of wine. Boil the medicinals until 7 fen remain, and then remove the dregs. Ingest the hot solution before meals, take the formula until diarrhea appears, this will relieve the abdominal pain. There is no need to drink the whole decoction.

(Modern use: chop all the medicinals into a crude powder, and prepare each dosage at 30 g. Decoct each dosage with yellow wine 30 ml.)

Formula Indications Fù Yuán Huó Xuè Tāng is indicated for injuries from falls, fractures, contusions, and strains, as well as, patterns of blood stasis marked by unbearable hypochondriac pain due to obstructive stasis.

Analysis of Fundamental Pattern Pathogenesis This pattern is due to traumatic injury causing blood stasis that lingers underneath the hypochondrium along with qi stagnation. The hypochondrium is coursed by the liver channel. Injuries cause blood stasis and qi stagnation, therefore pain, even very severe, occurs in the hypochondrium. The proper treatment method used for this pattern is to invigorate blood, dispel stasis, soothe the liver, move qi, and unblock the collaterals.

Formula Actions Invigorates blood and dispels stasis, soothes liver and unblocks the collaterals.

Formula Analysis

Continued

Unique Combination Features This formula regulates and circulates qi and blood by simultaneous ascending and descending and it activates blood and nourishes yin simultaneously in order to invigorate the blood and break up stasis, without the consumption of yin-fluids. Once the stasis has been removed and new blood has been generated, the hypochondriac pain will dissipate with the qi flowing freely in the collaterals.

Formula Applications 1. Essential pattern differentiation Fù Yuán Huó Xuè Tāng is commonly used for traumatic injuries and patterns of blood stasis obstruction. This clinical pattern is marked by:

● bruising, swelling, and pain in the lateral thorax

● all sorts of traumatic injuries when properly modified 2. Modifications

3. Modern applications Fù Yuán Huó Xuè Tāng may be used in the following biomedically defined disorders when the patient shows signs of obstructive blood stasis: intercostal neuralgia, rib cartilage inflammation, chest contusion, psychosis, and breast hyperplasia. 4. Cautions and contraindications It is suggested to stop taking the decoction once diarrhea occurs. However if the pain is relieved but the disease has not been cured after the diarrhea, the formula should be changed or the dosage should be decreased. This formula should not be taken by pregnant women.

Associated Formulas Qī Lí Săn (Seven Li Powder, 七厘散) [Source] Collection of Longevity (Tóng Shòu Lù, 同寿录) [Ingredients]

[Preparation and Administration] Grind the above into a fine powder, store in a china bottle, and seal with yellow wax for long-term preservation. [Actions] Dissipates blood stasis, diminishes swelling, stops pain, and stanches bleeding. [Applicable Patterns] Traumatic injuries, ruptured tendons, bone fractures, bruises and bumps, or bleeding due to incised wounds, pyogenic infections, and burns. External application may only be used for patients in chronic situations. To treat external injuries, take the formula (0.5-1 g) orally, infused with wine, and then paste the wound with the mix of medicinals and wine. For acute and severe situations, paste the powder directly on the wound (s). Fù Yuán Huó Xuè Tāng and Qī Lí Săn can invigorate blood, move qi, diminish swelling, relieve pain, and treat all kinds of swelling and pain due to traumatic injury causing blood stasis and qi stagnation. Fù Yuán Huó Xuè Tāng is good at invigorating blood, dispelling stasis, soothing the liver, and unblocking the collaterals. It can treat unbearable pain due to blood stasis at the hypochondrium. Qī Lí Săn has the advantages of invigorating blood, dissipating blood, stanching bleeding, and engendering flesh. It treats bruises, bumps, or bleeding wounds caused by injuries. Fù Yuán Huó Xuè Tāng can be used both internally as decoction and externally as application.

Case Studies Falling down A man fell down without excoriating the skin, but it caused distending pain in the hypochondrium. He had a fever, dry mouth, and spontaneous sweating, which seemed to be a wind syndrome. After drinking a bowl of urine collected from boys under 12 years old, the polydipsia stopped. After that he took one dose of Fù Yuán Huó Xuè Tāng with a double-dose of both chái hú and qīng pí and his distending pain disappeared. After he took another dose, he was healed. It is said in Classic of Invention (Fā Míng Jīng, 发明经), “when fallen from a height, blood stasis flows internally without differentiating whatever the channel is. The practiced and experienced doctors will consider it as wind attacking the liver channel, and treat it as wind-strike.”[10] The liver controls all the blood, as well as extravasated blood, therefore no matter which channel has been injured, blood stasis is certain to stay underneath the hypochondrium because the liver governs the blood. Severe pain is definitely accompanied with spontaneous sweating, and all sweating belongs to wind; while all pain pertains to liver. Furthermore extravasated blood stagnation is subordinate to the liver. The circulation of qi and blood definitely belongs to the liver. Falling down has an opposing effect on the qi and blood circulation, which is constraint. Treat it by breaking up the blood and unblocking the channel.1 1 Wei Zhi-xiu. Supplement to ‘Classified Case Records of Famous Physicians’ .Vol. 36 续名医类 案·卷36. Beijing: People’s Medical Publishing House; 2000.

Comments: Traumatic injuries, hypochondrium pain, fever, dry mouth, and spontaneous sweating were all symptoms of stasis obstructing the liver channel and heat due to stasis, so Fù Yuán Huó Xuè Tāng was used to treat this pattern. Urine was used to boost yin, clear heat and dispel stasis, and chái hú used at a heavy dose can conduct the other medicinals to the location

of disease and dissipate heat. Qīng pí reaches the liver to move qi and break up stasis. Qi flow promotes blood circulation in order to expel stasis and stop pain.

Wēn Jīng Tāng 温经汤Channel-Warming Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Decoct all of the medicinals with 1 dou of water, and boil down to 3 sheng. Take the warm decoction three times a day. (Modern use: prepare Wēn Jīng Tāng as a decoction, and mix in ē jiāo to melt into the decoction.)

Formula Indications

Wēn Jīng Tāng is indicated for deficiency-cold of the chong and ren mai, obstructive blood stasis marked by menstrual spotting or purple menses with blood clots. There may be irregular menstruation such as advanced, delayed, or prolonged periods, or having a period twice a month. There may also be inhibited menses, fever at night, vexatious heat in the palms, dry lips and mouth, distention and fullness of the lower abdomen, a dark red tongue, and a thready, choppy pulse. Infertility due to deficient cold of the uterus may also manifest.

Analysis of Fundamental Pattern Pathogenesis The pattern that Wēn Jīng Tāng treats is due to deficiency-cold of the chong and ren mai, and obstructive blood stasis. Chong is the sea of blood, and ren dominates pregnancy. They originate from the uterus, travel around the lower abdomen, and are closely related to menstruation and childbirth. Thefore, deficiency-cold of the chong mai and ren mai leads to obstructive blood stasis causing lower abdomen pain and fullness, irregular menstruation, or infertility. Obstructive blood stasis, blood leaving the vessels or chong mai and ren mai failing to astringe can lead to early, bimonthly, or flooding and spotting menstruation. Blood stasis due to cold accumulation can cause delayed or inhibited menses. Blood stasis blocking the generation of new blood leads to dry lips and mouth due to the lack of moisture. Fever at night and vexatious heat of the palms reflect internal heat generated from the consumption of blood. This pattern has multiple pathogenic factors including stasis, cold, deficiency, and heat; however, deficiency-cold of the chong mai and ren mai and blood stasis are the most prominent. The treatment is to warm the channels, dissipate cold, dispel stasis, nourish blood, and clear deficiency-heat.

Formula Actions

Warms the channels and dissipates cold, dispels stasis and nourishes blood.

Formula Analysis

Unique Combination Features

This formula uses the combination of four methods: warming, clearing, reinforcing, and dredging. Its focus is on warming the channels to remove stasis. The associated medicinals are warm in nature and reinforcing in function. They are coupled with medicinals that are cold and cool in nature to make the formula warm but not dry. The effect of the formula emphasizes warming and dissipating pathogenic cold. It combines dredging, warming and clearing within warming to make this a warming dredging and warming nourishing formula.

Formula Applications 1. Essential pattern differentiation Wēn Jīng Tāng is a fundamental formula for regulating menstruation in gynecology. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency-cold of the chong mai and ren mai and obstructive blood stasis: dysfunctional uterine bleeding, chronic pelvic inflammatory disease, irregular menstruation, uterine bleeding, dysmenorrhea, and infertility. 4. Cautions and contraindications This formula is not appropriate for irregular menstruation due to excessive heat or without blood stasis. Avoid raw or cold foods when taking this medication.

Associated Formulas Wēn Jīng Tāng (Channel-Warming Decoction , 温经汤) [Source] The Complete Compendium of Fine Formulas for Women (Fù Rén Dà Quán Liáng Fāng, 妇⼈⼤全良⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Warms the channels and supplements deficiency, dissolves stasis, and relieves pain.

[Applicable Patterns] Deficiency-cold of the sea of blood, syndrome of qi and blood stagnation. Symptoms include: menstrual irregularities, lower abdominal pain, and a deep, tight pulse. Ài Fù Nuăn Gōng Wán (Mugwort and Cyperus Palace Warming Pill , 艾附暖宫丸) [Source] [Yang] Ren-zhai’s Direct Guidance on Formulas (Rén Zhāi Zhí Zhĭ Fāng, 仁斋直指⽅) [Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills with the size of a phoenix tree seed using vinegar. 50-70 pills (6 g) are taken with light vinegar soup. [Actions] Warms the channels and supplements deficiency, rectifies qi, and invigorates blood. [Applicable Patterns] Deficiency-cold of the uterus. Symptoms include: white leukorrhea, yellowish complexion, tiredness, decreased appetite, irregular menstruation,

paroxysmal abdominal pain, and infertility.

Case Studies Menstrual block Ms. Weng had menstrual block for nine months, as well as a poor appetite. According to The Yellow Emperor’s Inner Classic, if menstruation doesn’t occur on time, the chong and ren mai are responsible. Chong mai, the sea of blood, is subordinate to yangming, referring to the stomach. Food and drink enter the stomach, which are then generated into essence and blood. Ying originates from the middle jiao. When yangming is deficient, it cannot generate enough essence and blood to nourish the chong and ren mai. Insufficiency of the chong and ren mai results in menstrual block. A modified Wēn Jīng Tāng, from the Essentials from the Golden Cabinet, treated the two yang channels. The formula was composed of dāng guī 2 qian, ē jiāo zhū 2 qian, zǐ dān shēn 2 qian, chì sháo 1.5 qian, bái sháo 1.5 qian, guì zhī 4 fen, wú zhū yú 4 fen, bàn xià (fresh) 2 qian, zhì gān căo 5 fen, chōng wèi zĭ 3 qian, chuān xiōng 8 fen, mŭ dān pí 1.5 qian, shēng jiāng 2 pieces, and dà zăo 2 pieces.1 Comments: As discussed in Basic Questions-Theory of Direct Access to the Highest Authorities in Ancient Times (Sù Wèn-Shàng Gŭ Tōng Tiān Lùn, 素问·上古通天论), “Women’s kidney essence matures at the age of fourteen, when the ren mai is open and the chong mai is prosperous, so menstruation begins.”[11] Chong is the sea of blood, ren is the sea of channels, and they both belong to yangming. In this case, menstrual block for nine months and a poor appetite reflect deficiency-cold of the chong and ren mai as well as obstructive blood stasis. Therefore, Wēn Jīng Tāng is applied. Dān shēn, chōng wèi zĭ, and chì sháo were to help invigorate the blood in order to treat the long-term menstrual block and severe stasis.

1 Shen Zhong-li. Collections of Case Records of Ding Gan-ren丁⽢仁临证医集. Shanghai: Shanghai Press of Traditional Chinese Medicine; 2000.

Shēng Huà Tāng ⽣化汤Engendering and Transforming Decoction Source Text Fu Qing-zhu’s [Treatise on] Gynecology (Fù Qīng Zhŭ Nǚ Kē, 傅青主 女科)

Formula Ingredients

Preparation and Administration Decoct the medicinals in equal amounts of yellow wine and infant’s urine. (Modern use: prepare Shēng Huà Tāng as a decoction, or decoct with a moderate amount of yellow wine.)

Formula Indications Patterns of blood deficiency, congealed cold, and blood stasis marked by inhibited lochia after childbirth and cold pain in the lower abdomen.

Analysis of Fundamental Pattern Pathogenesis

The pathogenesis of this formula is blood deficiency, congealed cold, and blood stasis. Following delivery women are deficient in qi and blood and are vulnerable to external cold contraction, leading to congealed cold and blood stasis. In this case lochia becomes retained and blood stasis blocks the uterus, causing cold pain in the lower abdomen; for where there is obstruction, there is pain. The therapeutic method is to nourish the blood, dissolve blood stasis, warm the channels, and relieve pain.

Formula Actions Nourishes the blood and dissolves blood stasis, warms the channels and relieves pain.

Formula Analysis

Continued

Unique Combination Features

This formula uses the combined methods of dissolving blood stasis with promoting regeneration in order to expel stasis and generate fresh blood. As Tang Zong-hai said, Shēng Huà refers to removing blood stasis and promoting regeneration, which is commonly used after childbirth.

Formula Applications 1. Essential pattern differentiation Shēng Huà Tāng is commonly used after childbirth. In some areas, it is a necessary formula to take after childbirth. Although this formula has its benefits, it is most suitable for those who have actual pattern of blood deficiency and obstruction from congealed cold. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of blood deficiency and congealing cold, blood stasis stagnation: poor involution of uterus, postpartum painful uterine contraction, and retained placenta.

4. Cautions and contraindications This formula should be used with caution in patterns associating with blood heat. It is contraindicated for profuse lochia, continuous bleeding, sweating, and shortness of breath.

Case Studies Abdominal pain Wang, an adult female, had scanty lochia after an abortion, as well as, palpitations and abdominal pain. She was given four dosages of a prescription composed of dāng guī 9 g, chuān xiōng 4.5 g, táo rén 4.5 g, zhì gān căo 4.5 g, páo jiāng 3 g, dān shēn 6 g, fú shén 12 g, méi gui huā 3 pieces. By her second visit, all of her symptoms were greatly alleviated, so she continued taking the same prescription.1 Comments: Lochia should be discharged after an abortion. However, symptoms such as scanty lochia, palpitations, and abdominal pain were caused by turbid blood stasis blocking the uterus in this patient. Therefore Shēng Huà Tāng was used. Fú shén can calm the mind and méi gui huā can move qi and relieve pain without damaging yin. Dān shēn can invigorate blood, dispel blood stasis, nourish blood, calm the mind, and relieve palpations.

Guì Zhī Fú Líng Wán 桂枝茯苓丸Cinnamon Twig and Poria Pill Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Grind all five medicinals into a fine powder, add honey, and make them into pills the size of rabbit droppings. Take①pill (3 g) before each meal, if it does not work, take 3 pills each time. (Modern use: take the honey pills 3-5 g a day. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios.)

Formula Indications Guì Zhī Fú Líng Wán is indicated for stasis obstructing the uterus; for instance, women who chronically have masses or lumps, menstrual spotting, restless fetus, dark purple menses, impalpable abdominal pain, painful

amenorrhea, or lochiorrhea. The tongue is dark purple with petechia, and the pulse is deep and choppy.

Analysis of Fundamental Pattern Pathogenesis 1 He Ren. Selected Case Records of He Ren 何任医案选. Hangzhou: Zhejiang Science and Technology Press; 1981.

Originally, this formula is indicated for women who consistently have masses or lumps, with a restless fetus and lochiorrhea associated with stasis obstructing the uterus. Masses and lumps associated with blood stasis that remain in the uterus lead to chong and ren disorders and insecurity of the fetus, which leads to a restless fetus. Stasis that obstructs the uterus and blocks the channels causes the blood to circulate abnormally and blood to leave the vessels, which leads to menstrual spotting. Stasis obstructs the uterus and the blood circulation is unsmooth. Obstruction causes pain so there are symptoms like abdominal pain that aggravates when pressed. The proper treatment is to invigorate blood and dissolve stasis, gradually eliminating masses or lumps.

Formula Actions Invigorates blood and dissolves stasis, gradually eliminates masses or lumps.

Formula Analysis

Unique Combination Features Guì zhī warms the channels and blood vessels. It is assisted by mŭ dān pí and sháo yào to cool blood and dissipate stasis. This formula uses both warming and cooling methods to prevent the consumption of yin-fluid. The treatment of metrostaxis by activating blood is the method of treating the flowing by promoting its flow. This formula has been mentioned in Fine Formulas for Women (Fù Rén Liáng Fāng, 妇⼈良⽅), in which it has been renamed Duó Mìng Wăn (Killing Pills) and described for the treatment of miscarriage caused by a fetus dying in the uterus, marked by severe choking sensation in chest, spontaneous cold sweating, and shortness of breath. In A Compendium of Female Disorders (Jì Yīn Gāng Mù, 济阴纲⽬), this formula is reformatted as a decoction named Cuī Shēng Tāng (Parturition Hastening Decoction), which can hasten the parturition for a painful abdomen and waist while the water is breaking.

Formula Applications

1. Essential pattern differentiation Guì Zhī Fú Líng Wán is commonly used to treat a restless fetus and lochiorrhea due to the retention of blood stasis in the uterus. This clinical pattern is marked by:

● masses in lower abdomen ● dark purple menses with blood clots ● pain in the lower abdomen that is worse when pressed 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of blood stasis accumulation: uterine fibroids, endometriosis, ovarian cysts, accessories inflammation, chronic pelvic inflammatory disease, and irregular menstruation. 4. Cautions and contraindications When treating masses in pregnant women, the blood-invigorating and stasis-dissolving methods should be used cautiously. In the original formula description, there are rigid rules regarding the dosage and administration worth paying attention to.

Case Studies

Body pain Chen, a married female adult, had her first visit on May 7th, 1963. At the end of March she gave birth. However, during the past forty days she suffered from prolonged lochia that was light red in color and of small quantity, with occasional purplish blood clots in it. Starting from the delivery, she had sore pain in her waist, and general pain when her body was pressed, which was worse in the lower part of the body. Sometimes she felt pain in the lower left abdomen. There were varicosities starting from the left waist down to the upper one-third part of her thigh. Other symptoms included poor appetite, loose stool, yellow urination, normal sleep, and a lusterless complexion. The pulse was powerful superficially but weak when it is deeply pressed. The right guān was wiry and slow while the left was wiry and big, both cùn and chĭ were deep and choppy. Her tongue was light red and was without coating. All of the problems were attributed to poor puerperal nursing, which led to the disharmony of ying and wei, and the disturbance of qi and blood leading to prolonged lochia. The treatment was to harmonize ying, wei, and blood in order to eliminate stasis. she was given five doses of a prescription composed of guì zhī 4.5 g, bái sháo 6 g, fú líng 9 g, mŭ dān pí 3 g, táo rén 3 g, páo jiāng 2.4 g, and dà zăo 4 pieces. She had her second visit on May 16th. By that time the lochia and the pain in the abdomen, waist, and legs had all gone, her appetite improved, and her urine and stool returned to normal. Her pulse was deep, wiry, and slightly rapid and her tongue was pale without coating, which showed that the stasis had dissolved. The treatment thereafter was to supplement the qi and blood. She was given forty pills of Shí Quán Dà Bŭ Wán (a patented pill form of Shí Quán Dà Bŭ Tāng). She took one pill each morning and evening until she finally healed.1

1 Academy of Traditional Chinese Medicine. Case Records of Pu Fu-zhou 蒲辅周医案. Beijing: People’s Medical Publishing House; 1972.

Comments: Forty days after delivery, the patient had prolonged lochia, pain in the waist, abdomen, and even her whole body, as well as, loose stool. It was recorded in the Golden Mirror of the Medical Tradition, “the cause of prolonged lochia can be deficiency of the chong mai and ren mai failing to control the blood, or blood stasis remaining inside the abdomen.” The book also said, “slight puerperal abdominal pain is due to incomplete elimination of blood clots during childbirth, called postpartum abdominal pain.” The lochia is light red, the tongue is light red without coating, and the pulse feels strong superficially but weak if deeply pressed. These are the manifestations of poor puerperal nursing and deficiency of the chong mai and ren mai. Purple lochia with blood clots, painful abdomen, varicosities at the waist and the upper one-third of the thigh are the manifestations of blood stasis. General pain means a disharmony of ying and wei, which was treated with a modified Guì Zhī Fú Líng Wán. Guì zhī, bái sháo, and dà zăo harmonize ying and wei. Páo jiāng and fú líng warm and stimulate the channels. Táo rén and mŭ dān pí dissipate stasis and circulate blood. After taking the pills all the pain was gone and the stool normalized, which meant the stasis was expelled and the ying and wei was functioning harmoniously. Therefore, Shí Quán Dà Bŭ Wán was used to reinforce the qi and blood for a better recovery.

Shī Xiào Săn 失笑散Sudden Smile Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Mix condensed vinegar, stew into paste, decoct with 1 cup of water and boil them down until 70% remains, and take the warm decoction before meals. (Modern use: grind them into fine powder, 6 g in one dosage, take the powder with yellow wine or vinegar; or wrap 8-12 g powder in gauze and decoct.)

Formula Indications Shī Xiào Săn is indicated for pain due to blood stasis such as stabbing pain in the chest and abdomen, inhibited lochia, irregular menstruation, and acute pain in the lower abdomen.

Analysis of Fundamental Pattern Pathogenesis The varieties of pains that are addressed by this formula are all caused by blood stasis obstructing the blood vessels. Stabbing pain of the chest and

abdomen, and acute pain in the lower abdomen are due to poor blood circulation from obstructed blood vessels. Irregular menstruation and inhibited lochia are caused by stasis blocking the uterus. The treatment method is to invigorate blood, dissolve stasis, dissipate masses, and relieve pain.

Formula Actions Invigorates blood and dissolves stasis, dissipates masses and relieves pain.

Formula Analysis

Unique Combination Features This formula is simple as it consists of just two medicinals. However this shows its significant effect on eliminating stasis, relieving pain, and promoting regeneration. By using this formula, patients in ancient times were cured without knowing it. At some point in time, they suddenly find that they have

recovered and burst into laughter. That is why the formula is named “sudden smile”.

Formula Applications 1. Essential pattern differentiation Shī Xiào Săn is a basic formula for treating pain patterns caused by blood stasis. It is most suitable for blood stasis of the liver channel. This clinical pattern is marked by:

● stabbing pain of the chest and abdomen ● menstrual irregularities ● acute pain of lower abdomen 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of blood stasis accumulation: dysmenorrhea, coronary heart disease, elevated blood lipid levels, ectopic pregnancy, and chronic gastritis.

4. Cautions and contraindications This formula is contraindicated during pregnancy. It should be used cautiously for patients with spleen and stomach deficiency or for women when they are having their period.

Associated Formulas Dān Shēn Yĭn (Salvia Beverage, 丹参饮) [Source] Summary Verses of Post-classical Formulas (Shí Fāng Gē Kuò, 时⽅歌 括) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Invigorates blood, dispels stasis, moves qi, and relieves pain. [Applicable Patterns] All pains associated with the heart or stomach due to blood stasis and qi stagnation. Huó Luò Xiào Líng Dān (Effective Channel-Activating Elixir, 活络效 灵丹) [Source]

Records of Chinese Medicine with Reference to Western Medicine (Yī Xué Zhōng Zhōng Cān Xī Lù, 医学衷中参西录) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. When used as powder, it should be taken with warm wine. [Actions] Invigorates blood, dispels stasis, unblocks the collaterals, and relieves pain. [Applicable Patterns] Blood stasis and qi stagnation. Symptoms include: pain in the heart, abdomen, legs, or arms, traumatic injuries, internal or external sores and ulcers, and abdominal masses. Dān Shēn Yĭn and Huó Luò Xiào Líng Dān both share blood stasis and qi stagnation as the same pathogenesis, and dān shēn as the chief medicinal. Meanwhile, they have differences in their capabilities. Huó Luò Xiào Líng Dān has a better effect to activate the blood, expel stasis, and stop pain. This is because it contains rŭ xiāng, mò yào, and dāng guī, which also prevent blood damage. Dān Shēn Yĭn has a better effect to move qi and stop pain. This is because it contains tán xiāng and shā rén, which can protect yin. For this reason, Dān Shēn Yĭn is regarded as an effective formula for all pains in the heart and abdomen, abdominal masses, and traumatic injuries due to

blood stasis, where Huó Luò Xiào Líng Dān is usually used for all pains in the heart or stomach due to blood stasis and qi stagnation.

Case Studies Abdominal pain Once there was a Chinese doctor named Li Zhai. He cured a woman who had profuse menstruation. She had been wrongly treated by astringent medicinals, which led to abdominal pain. She was better after taking two doses of Shī Xiào Săn. The formula was prepared by stir-frying equal doses of wŭ líng zhī and pú huáng, each dose 2-3 qian, mixing in a moderate amount of vinegar, and boiling this mixture down into paste. Then, add some water to make a decoction, and take the warm decoction before meals. Following this treatment, the profuse menstruation was further treated with Jiā Wèi Xiāo Yáo Săn.1 Comments: The chief complaint of this case was profuse menstruation that was improperly treated by astringent medicinals. They stopped the menstruation, but at the expense of abdominal pain. As a result, there was retention of blood stasis, obstruction of blood vessels, and poor blood circulation. Therefore, the doctor prescribed Shī Xiào Săn to invigorate blood, dispel stasis, dissipate masses, and relieve pain. In two doses, the patient got well. Furthermore, Jiā Wèi Xiāo Yáo Săn was used to fortify the spleen, nourish the blood, soothe the liver, and regulate qi for better recovery.

Dà Huáng Zhé Chóng Wán ⼤黄䗪⾍丸Rhubarb and Eupolyphaga Pill Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Grind all of the medicinals into a fine powder. Form them into honey pills as big as a bean. Take 5 pills (3 g) with wine, three times a day. (Modern use: skewer qí cáo separately, mash táo rén and xìng rén separately. Pulverize the rest and sift them. Mix all of the medicinals and make them into a fine powder. Add honey to make pills, 3 g for each pill, and seal with wax. Take 1 pill at a time with warm water or wine.)

Formula Indications 1 Wei Zhi-xiu. Supplement to ‘Classified Case Records of Famous Physicians’. Vol. 23 续名医类 案·卷23. Beijing: People’s Medical Publishing House; 2000.

Dà Huáng Zhè Chóng Wán is indicated for severe deficiency due to exhaustion or lesions from the five labors, and the retention of dried blood due to internal deficiency-heat. The symptoms and signs are marked by emaciation, contractions or spasms in the lower abdomen, abdominal pain which is worse with pressure or the pain which cannot be relieved by pressure, fullness of the stomach and poor appetite, scaly skin, dull and lusterless eyes, dark eyes, a tongue body with ecchymosis, and a pulse that is deep, choppy or wiry.

Analysis of Fundamental Pattern Pathogenesis The dried blood is caused by long-term severe deficiency due to exhaustion from the five labors, damage of ying and wei qi in the channels and collaterals, and congealing of blood in the vessels. As said in Basic Questions, “prolonged seeing consumes blood, prolonged lying consumes qi, prolonged sitting consumes muscles, prolonged standing consumes bones, and prolonged walking consumes tendons, called exhaustion due to five terms of labors.”[12] Long-term obstruction of dried blood turns into heat, consumes yin and blood, and fails to nourish the skin causing scaly skin. Yin and blood deficiency fails to move upward and nourish the eyes, so the eyes are black. Transformation and transportation becomes a problem due to a functional disorder of the spleen and stomach leading to fullness of the stomach and no desire for food. Poor transformation and transportation of the essence of water and grain fails to nourish the body, so there is emaciation. Ecchymosis on the tongue and a choppy pulse refers to blood stasis. The root of this pattern is excessive deficiency due to exhaustion from

the five labors. The branch is long-term stasis of dried blood, so it is the deficiency that causes the stasis. However, considering that there are acute symptoms due to stasis retention, the branch should be treated first. Therefore, expelling stasis is the main treatment method. If blood stasis is removed, then fresh blood will be regenerated and the zheng qi recovered. Tang Rong-chuan said, “fresh blood can never be produced unless the old blood is removed. People only know that dried blood is a serious deficiency syndrome, but they don’t know that the reinforcing method can only assist the development of the disease, rather than curing it. The dried blood should be removed first, and then the new blood can be produced. Therefore, there is chance for recovery.”[13] (Treatise on Blood Syndromes) Therefore, the mild purgation method should be used for people who are in an extremely weak condition. In this situation one could use manufactured pills to expel the stasis gently and gradually.

Formula Actions Dispels blood stasis and regenerates new blood.

Formula Analysis

Continued

Unique Combination Features This formula combines purgation with supplementation in order to remove blood stasis and clear stagnated heat, without damaging the zheng qi.

Formula Applications 1. Essential pattern differentiation Dà Huáng Zhè Chóng Wán is indicated for patterns of blood stasis due to exhaustion. It is also used to treat menstrual block due to dry blood retention. Moreover, a tonic prescription should be applied when the dried blood is removed in order to get an overall effect. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is usually used in the following biomedically defined disorders when the patient shows signs of blood stasis: cirrhosis of the liver, hepatosplenomegaly, intestinal adhesion, appendix mass, ectopic pregnancy, and uterine fibroids. 4. Cautions and contraindications This formula is contraindicated during pregnancy.

Associated Formulas Biē Jiă Jiān Wán (Turtle Shell Decocted Pill, 鳖甲煎丸) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Excluding xiāo shí, biē jiă, and ē jiāo, bake and break the remaining twenty medicinals, mix them up with 600 g of yellow wine, seal and boil till the wine is completely volatilized. Dry the dregs and mix with xiāo shí, biē jiă, and ē jiāo, make 3 g honey pills. Take 1 or 2 pills 2 or 3 times a day with warm water. [Actions] Moves qi, invigorates blood, dispels dampness, dissolves phlegm, softens hardness, and disperses lumps. [Applicable Patterns] Chronic malaria with masses below the costal region and abdominal masses. Longlasting malaria causes masses to gather underneath the costal region. It is called chronic malaria with masses. Symptoms include: masses underneath the costal region that stay firm when pushed, abdominal pain, weak muscles, decreased appetite, occasional cold or fever, and inhibited menses. Xià Yū Xuè Tāng (Blood Stasis-Expelling Decoction, 下瘀⾎汤)

[Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Grind these medicinals into a fine powder. Form into four honey pills, add 1 sheng of wine, make one pill, take 8 ge at once, then the new refreshed blood will flow immediately. [Actions] Drains heat and expels stasis. [Applicable Patterns] Heat pattern due to blood stasis, patterns of combined heat and stasis. Symptoms include: painful lower abdomen that is worse with pressure following childbirth, gelosis felt upon pressure, inhibited lochia, dry mouth, dry stool, dry and scaly skin, a purple red tongue body with ecchymosis, a dry yellow coating, and a deep, choppy and strong pulse. It also treats scanty menstruation due to blood stasis.

Section 2 Formulas that Stanch Bleeding Formulas that stanch bleeding are used to treat all sorts of hemorrhages due to blood failing to travel inside of the blood vessels. Examples include hematemesis, epistaxis, hemoptysis, bloody stool, bloody urine, and flooding and spotting menses. Due to the complicated pathogenesis that leads to hemorrhages, hemostatic formulas should be prescribed flexibly on the basis of the cause, the location, and the tendency of the disease. Generally, for blood heat, the treatment is to cool blood and stanch bleeding. Use medicinals that cool blood and stanch bleeding such as xiăo jì, cè băi yè, bái máo gēn, and huái huā accompanied with some heat clearing medicinals. For yang deficiency failing to control the blood, the treatment is to warm yang and stanch bleeding. Use medicinals such as zào xīn tŭ, páo jiāng, ài yè, and zōng lǚ tàn accompanied with some medicinals that tonify yang and supplement qi. For chong mai and ren mai deficiency, the treatment is to nourish blood and stanch bleeding. Use blood nourishing medicinals such as ē jiāo accompanied with medicinals that reinforce the chong mai and ren mai. For hemorrhage of the upper jiao, add medicinals that can conduct the blood downward, such as niú xī and dài zhĕ shí. For hemorrhage of the lower jiao, add medicinals that have the function to promote, such as burnt jiè suì and shēng má. For acute massive hemorrhage, the priority is to stop the bleeding, because in an emergency situation, treat the branch. If there is qi exhaustion resulting from a hemorrhage, reinforce the vital qi as priority in order to relieve the desperate situation. For chronic hemorrhaging, focus on treating the root or the root and branch both. For hemorrhage with blood stasis, add some medicinals that invigorate blood and dispel stasis to prevent the retention of the stasis when stanching the bleeding. In the meantime,

when treating hemorrhages, the focus should be on treating the root instead of only stopping the bleeding. When stanching blood, remember to take the cause of the hemorrhage into consideration. Representative formulas are Shí Huī Săn, Ké Xiě Fāng, Xiăo Jì Yĭn Zĭ, Huái Huā Săn, and Huáng Tŭ Tāng.

Shí Huī Săn ⼗灰散Ten Charred Substances Powder Source Text Divine Book of Ten Medicinal Formulas (Shí Yào Shén Shū, ⼗药神书)

Formula Ingredients

Preparation and Administration Char the medicinals, but take care to retain their medicinal properties. Grind them into a fine powder, wrap them with paper, cover them with a bowl on the ground for one night in order to get rid of the fire toxin, and use

either white lotus root juice or radish juice to grind 0.5 bowl of Peking ink. Mix 5 qian of the powder, and take after meals. (Modern use: char the medicinals, but take care to retain their medicinal properties. Grind them into a fine powder; use either white lotus root juice or radish juice to grind the right amount of Peking ink. Mix 9-15 g of the powder and take it. Or make a decoction, adjusting the dosages according to the proportions of the original formula.)

Formula Indications Shí Huī Săn is indicated for hemorrhages due to blood heat. Examples include vomiting of blood, spitting of blood, expectoration of blood, coughing of blood and nosebleed. If the color of the blood is bright red, the situation is acute and severe. The tongue body is red and the pulse is rapid.

Analysis of Fundamental Pattern Pathogenesis This formula is indicated for all kinds of hemorrhages of the upper jiao. The cause of the hemorrhage is flaming heat moving upward and damaging the blood vessels, then blood travels out of the normal pathway. The treatment principle is to cool blood and stanch bleeding.

Formula Actions Cools blood and stanches bleeding.

Formula Analysis

Unique Combination Features Stanch bleeding while clearing heat and draining fire. Expelling stasis is included into the procedure of cooling blood and draining fire.

Formula Applications 1. Essential pattern differentiation Shí Huī Săn is indicated for all kinds of hemorrhages in the upper jiao due to blood heat. This clinical pattern is marked by:

● bright red blood ● red tongue body with a yellow coating ● rapid pulse 2. Modifications

3. Modern applications This formula can be used in the following biomedically defined disorders when the patient shows signs of hemorrhage due to blood heat: upper gastrointestinal hemorrhage, bronchiectasis, and hemoptysis due to tuberculosis, etc. 4. Cautions and contraindications This formula is used to treat the branch in acute circumstances. However, once the bleeding has been brought under control, the root of the problem should be identified in order to further increase efficacy of the treatment. Shí Huī Săn is not suitable for patterns of deficiency-cold. Since it is a powder, it can be used for either internal or external treatment. No matter how it is used, prepare it in advance and use it to decrease blood heat. Although these medicinals are to be charred, when doing so take care to make sure that their medicinal properties remain intact, otherwise the reliability of their medicinal effect will be uncertain.

Associated Formulas Sì Shēng Wán (Four Fresh Medicinals Pill, 四⽣丸) [Source] The Complete Compendium of Fine Formulas for Women (Fù Rén Dà Quán Liáng Fāng, 妇⼈⼤全良⽅)

[Ingredients]

[Preparation and Administration] Grind the ingredients into powder and form into pills with the size of yolk. 1 pill (6 g) is taken as one dose. It can also be prepared as decoction. [Actions] Cools the blood and stanches bleeding. [Applicable Patterns] Hemorrhage due to blood heat. Symptoms include: spitting of blood, nosebleed with bright red blood, dry mouth and throat, a red or crimson tongue, and a wiry, rapid pulse. Sì Shēng Wán and Shí Huī Săn both have the function to cool the blood and stanch bleeding, and they both treat hemorrhages in the upper jiao due to blood heat. Because of the charring of its medicinals, which is a process that stanches bleeding, Shí Huī Săn is focused on treating the branch. Where Sì Shēng Wán contains all fresh, raw medicinals and can treat both the root and branch.

Case Studies Nosebleed Mr. Guo, a 40-year-old worker had his first visit on March 2nd, 1978. He had a chronic pulmonary disease, and sometimes he had bloodstained sputum. Lately, his nose would bleed when fatigued. His pulse was big and a little rapid, and his tongue coating was thin and yellow. His pattern was

differentiated as lung heat. Because the lung opened into the nose, there was nosebleed. The therapeutic principle was to clear heat and stanch bleeding. The formula prescribed was Shí Huī Wán (in this case it was a patented manufactured Shí Huī Săn) 12 g each time, twice a day. After ten days’medication, the nosebleed was cured.1 Comments: In this case, the patient had a chronic pulmonary disease and bloodstained sputum. Lately, he had nosebleeds when he was fatigued from overwork. His tongue coating is thin and yellow, and his pulse is big and a little rapid. This indicated that counterflowing qi and fire caused the blood to flow abnormally. Therefore, Shí Huī Săng was used to cool blood and stanch bleeding in order to conduct the heat downward.

Ké Xuè Fāng 咳⾎⽅Coughing with Blood Treating Decoction Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

Preparation and Administration Grind these medicinals into a fine powder, and make pills using honey and ginger juice. Dissolve the pill in the mouth. (Modern use: Grind these medicinals into fine powder, take 9 g a dose. It can also be used as decoction, adjust the dosage according to the proportion of the origin formula.)

Formula Indications Syndrome of hemoptysis due to liver fire invading the lung marked by cough, thick bloodstained sputum, difficulty in spitting, vexation, irascibility, chest pain, dry throat, bitter taste in the mouth, flushed complexion, and

constipation. The tongue body is red and the coating is yellow, and the pulse is wiry and rapid.

Analysis of Fundamental Pattern Pathogenesis 1 Lian Jian-wei. Famous Formulas Selections of Past Dynasties 历代名⽅精编. Hangzhou: Zhejiang Sciences and Technology Publishing House; 1987.

This pattern is caused by liver fire invading the lung and damaging the blood vessels. Of all the zang-fu organs, the lung is the most delicate and pure. If burned by the liver fire, the lung fluid becomes sputum. If it fails to purify and descend, the sputum will become thick and hard to expectorate. When liver fire burns the lung and damages the lung’s collaterals, the blood will overflow upward and there will be bloodstained sputum. Due to the flaming of liver fire, there is vexation, irascibility, chest pain, dry throat, bitter taste in the mouth, flushed complexion, and constipation. A red tongue body and a yellow coating, and a wiry, rapid pulse are signs of flaming fire. The location of the disease is in the lung, but the root of the disease is in the liver. According to the therapeutic principle, clear the liver heat and drain fire to treat the root. When the fire is cleared and qi descended, the lung can work normally.

Formula Actions Clears liver heat and calms the lung, cools blood and stanches bleeding.

Formula Analysis

Unique Combination Features This formula uses the combined methods of stanching bleeding, clearing heat, and draining fire rather than using hemostatics alone. Blood can flow normally if fire heat is cleared; this refers to the method of treating the root.

Formula Applications 1. Essential pattern differentiation Ké Xuè Fāng is usually indicated for patterns of hemoptysis caused by liver fire invading the lung. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver fire invading the lung: hemoptysis of bronchiectasis or tuberculosis. 4. Cautions and contraindications This formula is cold, cool, descending, and drastic in nature. It is not suitable for patterns of lung-kidney yin deficiency or diarrhea due to spleen deficiency.

Associated Formulas Dài Gé Săn (Natural Indigo and Clam Shell Powder, 黛蛤散) [Source] Explanation of Medicine (Yī Shuō, 医说) [Ingredients] Qīng dài and hăi gé qiào in equal doses, grind into powder. [Preparation and Administration] Grind the ingredients into fine powder. 6-9 g are wrapped and prepared as decoction. [Actions]

Clears liver heat and dissolves phlegm. [Applicable Patterns] Liver fire invading the lung, burning the fluid into phlegm. Symptoms include: cough, thick, yellow sputum, or yellow and white, thick sputum, and pain in the chest or rib-side.

Case Studies Coughing of blood He patient was a 60-year-old female. Her chief complaints were coughing of blood five to twenty times each day, as well as, coughing and pain and fullness in the chest and hypochondrium for one month. She had a ten-year history of coughing blood. She had been diagnosed with bronchiectasis according to the signs of the disease, verified by chest X-ray and bronchial lipiodolography. There was no obvious relationship between the onset and the season or climate, but the hemoptysis usually occured when she became angry or was in a bad mood. The amount of blood coughed up was small, and the bleeding could last for a few months. One month ago, after becoming furious, she felt fullness in her chest and distending pain in her hypochondrium that was caused by frequent coughing. She then coughed up nearly 100ml of fresh blood. She was sent to the emergency unit of a hospital, where she was given an intravenous injection of 10 u pituitrin that stopped the severe hemoptysis. However, she continued to cough up blood five to twenty times every morning. She was given adrenobazonum and vitamin K3 as hemostatics, penicillin as an antiinflammatory agent, and codeine as an antitussive drug. However, they failed to decrease the amount of bleeding, and sometimes the amount of bleeding even increased. By that time, she became distressed by her continuous

coughing of blood, and developed additional symptoms such as vexation and irritability. Her tongue was red with a yellowish coating, and her pulse was wiry and rapid. Her blood pressure was 170/100 mmHg. Chest auscultation revealed a bubbling sound in the lower part of the right lung. Chest radiography revealed an increase of bronchovascular shadows, disordered lung markings, and scattered dot shadows with blurred margins in the lower part of the right lung. The Chinese medicine diagnosis was coughing of blood due to liver fire invading the lung. Three doses of a modified Ké Xuè Fāng was prescribed composed of guā lóu 20 g, hē zĭ 15 g, zhī zĭ 15 g, hăi fú shí 15 g, mài dōng 15 g, mŭ dān pí 10 g, and qīng dài 5 g (infused). By the second visit the patient reported that all the symptoms including fullness of the chest, cough, and distending pain in hypochondrium were alleviated. The amount of bleeding decreased and she coughed up blood only two to three times a day. Her tongue remained red and her pulse was still wiry and rapid. Therefore, she was prescribed three more dosages of the previous formula. On the third visit the patient came in delight. The pain in the chest and hypochondrium were greatly alleviated, the cough was lightened, and the coughing up of blood was well controlled with only a little blood-stained sputum. She was prescribed three more dosages of the original formula. Afterwards, the coughing up of blood was totally stopped. The symptoms, tongue, and pulse returned to normal. Furthermore, the bubbling sound in the lower right lung evidently decreased. She was observed for two months, during which time she did not have any more coughing up of blood. However, three months later she coughed up blood again when she had bad mood again. After taking six dosages of the previous formula, she recovered and could return to housework in one week.1

Comments: In this case, hemoptysis was triggered by bad mood. It was accompanied with distending pain in the hypochondrium, vexation, chest suppression, a red tongue body with a yellow coating, and a wiry and rapid pulse, which are due to liver fire invading the lung. Hence Ké Xuè Fāng is used to clear liver fire and calm the lung. Mŭ dān pí further helped to cool and stanch bleeding, and mài dōng nourished yin to moisten the lung and prevent yin damage from the bleeding. The formula matched the pattern differentiation, so the hemoptysis was cured.

Xiăo Jì Yĭn Zĭ ⼩蓟饮⼦Field Thistle Drink Source Text Formulas to Aid the Living, recorded in Essential Mechanism and Delicate Significance (Yù Jī Wēi Yì, ⽟机微义)

Formula Ingredients

1 Gao Yong-xiang, Wang Yi-lin. Experience Gained in Treating Hemoptysis by Ké Xuè Fāng 咳 ⾎⽅临证⼀得. Heilongjiang Journal of Traditional Chinese Medicine. 1987; (1): 45.

Preparation and Administration Cut the medicinals in to small pieces, for every dose use 0.5 liang (15 g), take the decoction before meals. (Modern use: Prepare it as decoction, adjust the dose according to the state of disease.)

Formula Indications

Blood strangury or bloody urine is due to the accumulation of heat in the lower jiao. This condition is marked by blood in the urine, and frequent painful urination that is hot with an unsmooth stream. The tongue is red and the pulse is rapid.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by stagnant heat in the lower jiao that has damaged the blood collaterals of the bladder and affected qi transformation. Heat accumulated in the bladder damages blood collaterals. Bleeding occurs and the blood is discharged with the urine, so there is blood in the urine. Urination accompanied with pain is called blood strangury, or bloody urine. The heat caused by the stasis that has accumulated in the lower jiao affects the qi transformation of bladder, so there is frequent painful urination that is hot with an unsmooth stream that contains blood. The red tongue and rapid pulse are signs of heat accumulation. The treatment method is to cool blood, stanch bleeding, promote urination, and relieve strangury.

Formula Actions Cools blood and stanches bleeding, promotes urination and relieves strangury.

Formula Analysis

Unique Combination Features The foundation of this formula is Dăo Chì Săn, which can clear heart fire and nourish yin. With the addition of xiăo jì, ŏu jié, pú huáng, huá shí, zhī zĭ, and dāng guī, this formula cools, stanches blood, promotes urination, and relieves strangury. Removing stasis when stanching blood prevents retention of stasis. Nourishing the yin during the process of clearing and promoting urination can protect the zheng qi.

Formula Applications 1. Essential pattern differentiation

Xiăo Jì Yĭn Zĭ is frequently used to treat patterns of blood strangury and bloody urine due to excessive heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of stagnant heat accumulating in the lower jiao: acute urinary system infection, urinary calculus, and nephrotuberculosis. 4. Cautions and contraindications The medicinals in this formula are mostly cold and cool, and lubricating and percolating in function. So they can only be indicated for patterns of excessive heat. It should not be used for chronic blood strangury and bloody urine with cold symptoms, yin deficiency with stirring fire, or qi deficiency that fails to control.

Case Studies Bloody urine

Tang, a 9-year-old male, diagnosed with acute nephritis, visited the doctor because he had bloody urine for two days. His other signs and symptoms included gross hematuria and a burning sensation during urination. His urination was not painful, the tongue coating was yellow and greasy, and the pulse was wiry. Xiăo Jì Yĭn Zĭ was prescribed to him. After taking three dosages, the color of his urine lightened and a routine urine test showed positive (+) for protein in his urine, although it may have been a small amount. As viewed under the microscope, the RBC decreased to 8-10, and the ESR (erythrocyte sedimentation rate) was 39 mm/h. A modified Xiăo Jì Yĭn Zĭ was prescribed to him. When there was slight edema, Dà Jú Pí Tāng was used, and when the edema was gone, Liù Wèi Dì Huáng Tāng was used for rehabilitation.1 Comments: Acute nephritis is primarily marked by bloody urine, without obvious edema. It most often is related to wind-heat invading the lung, or yin deficiency and internal heat causing bleeding. If there are no signs of wind-heat invading the lung, then the treatment is to clear heat and cool blood with Xiăo Jì Yĭn Zĭ.

Huái Huā Săn 槐花散Pagoda Tree Flower Powder Source Text Experiential Formulas for Universal Relief (Pŭ Jì Bĕn Shì Fāng, 普济 本事⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine powder, and take with rice soup before meals. (Modern use: grind the medicinals into a fine powder, take with warm water or rice soup. It can also be prepared as a decoction by adjusting the dosages according to the proportions of the original formula.)

Formula Indications The formula is used for patterns of wind heat and damp toxins obstructing the intestines and damaging blood vessels. Bleeding that occurs either before or after defecation, blood stained stool, or hemorrhoid bleeding marks this pattern. The color of the blood can be either bright or dark, the tongue is red with a yellow coating, and the pulse is rapid.

Analysis of Fundamental Pattern Pathogenesis

The indication of this formula is to treat intestinal wind or visceral toxins due to wind heat, or damp toxins obstructing the intestines and damaging the blood vessels. Generally speaking, “the blood from intestinal wind is fresh and bright red, and it bleeds in full fury before stool is evacuated. While the blood from viscera toxins is dark and defecated either before or after stool is evacuated.”[14] (Convenient Reader on Established Formulas, chéng Fāng Biàn Dú, 成⽅便读). The primary therapeutic principle is to cool the blood and stanch bleeding, which is assisted by scattering wind and moving qi.

Formula Actions Clears the intestines and stanches bleeding, scatters wind and moves qi. 1 Shi Zhen-sheng. Medical Description of Doctor Shi 时门医述. Beijing: China MedicoPharmaceutical Sciences and Technology Publishing House; 1994.

Formula Analysis

Formula Applications 1. Essential pattern differentiation

Huái Huā Săn is used to treat hemafecia due to intestinal wind or damp heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of wind heat or damp heat toxins obstructing the intestines and damaging the blood vessels: hemorrhoid, colonitis, intestinal cancer, or hematochezia originating elsewhere. 4. Cautions and contraindications Since these medicinals are cold and cool in nature, it should only be used for temporary administration rather than for long term use. It is not suitable for bloody stool due to qi deficiency or yin deficiency or weakness of the spleen and stomach.

Associated Formulas Huái Jiăo Wán (Japanese Pagoda Tree Pod Pill, 槐角丸) [Source]

Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Grind the medicinals in a powder, mix with wine to form pills as big as a phoenix tree seed. Take 30 pills each time (15 g) with rice soup whenever there is bleeding. To make a decoction, the dosages can be decreased according to the origin proportions. [Actions] Clears the intestines and dispels wind, eliminates accumulation and discharges heat. [Applicable Patterns] Hemorrhoid, prolapse of the rectum due to wind heat or damp heat toxins.

Case Studies Bloody stool Mr. Hu had been attacked by wind, which invaded the spleen and caused damp heat to accumulate in the ying level and blood to permeate the large intestine. This led to the reappearance of bloody stool and symptoms of internal heat and poor appetite. His tongue coating was thin, greasy, and yellow, and his pulse was soggy, slippery, and rapid. The pathogen was

increasing and it lingered, therefore it was necessary to urgently clear ying heat, expel wind, and strengthen the spleen to resolve dampness. The prescription was composed of jīng jiè suì tàn 1 qian, huái huā tàn 3 qian, fú líng 3 qian, bái zhú 1.5 qian, gān căo 5 fen, yīn chén 2 qian, yì yĭ rén 4 qian, jiāo gŭ yá 4 qian, cè băi yè tàn 1.5 qian, chì xiăo dòu 1 liang, chén pí 1 qian, gān shì bǐng (dried persimmon) 3 qian, and ŏu jié tàn 2 pieces.1 Comments: In this case, the patient suffers from a reoccurrence of bloody stool, marked by internal heat and poor appetite. His tongue coating was thin, greasy, and yellow, and his pulse was soggy, slippery, and rapid. His condition was chronic belonging to wind heat or damp heat toxins obstructing the intestines. The prescription was based on Huái Huā Săn with chì xiăo dòu and dried persimmon added to improve the ability to cool blood. Fú líng, yīn chén, and yì yĭ rén were added to clear heat and resolve dampness of the spleen and stomach. Bái zhú, chén pí, and gŭ yá were added to reinforce or activate the deficient spleen qi.

Huáng Tŭ Tāng 黄⼟汤Yellow Earth Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

1 Shen Zhong-li. Clinical Case Records of Ding Gan-ren丁⽢仁临证医集. Shanghai: Shanghai Press of Traditional Chinese Medicine; 2000.

Preparation and Administration Decoct the medicinals above with 8 sheng of water untill there is 3 sheng of water remaining. Take the warm decoction twice a day. (Modern use: decoct zào xīn tŭ first, then use the decoction to decoct the other medicinals, and finally infuse ē jiāo by melting it into the decoction.)

Formula Indications Huáng Tŭ Tāng is indicated for the pattern of spleen yang insufficiency and spleen failing to control the blood. The symptoms are bloody stool, in which the stool comes out first, spitting of blood, nosebleed, flooding and

spotting (bēng lòu) of dark colored menstrual blood, cold limbs, sallow complexion, a pale tongue with a white coating, and a deep, thin and weak pulse.

Analysis of Fundamental Pattern Pathogenesis The pattern that this formula treats is spleen yang deficiency failing to control the blood. Normally the spleen governs the blood. However, when the spleen yang is deficient, it fails to control the blood and keep it contained inside the vessels. Blood can overflow from the upper jiao to cause bleeding such as spitting blood and nosebleeds. Also blood can overflow from the lower jiao to cause bark-colored bloody stool and flooding and spotting (bēng lòu), cold limbs, sallow complexion, a pale tongue body with a white coating, and a deep, thin and weak pulse. All of the symptoms above belong to a pattern of deficient cold in the middle jiao, as well as, yin and blood deficiency. The primary treatment method is to warm yang and stanch bleeding, which is assisted by fortifying the spleen and nourishing blood.

Formula Actions Warms yang and fortifies the spleen, nourishes blood and stanches bleeding.

Formula Analysis

Unique Combination Features The medicinals in this formula utilize various combinations of treatment methods. They include using both warm and cold medicinals, treating both root and branch, and alternating the use of gentle and strong medicinals. Strong medicinals warm the yang without damaging the yin. Gentle medicinals nourish yin without damaging yang. Wu Tang said this formula demonstrates, “the combination of sweet and bitter, as well as, kindness with severity.”[15] (Systematic Differentiation of Warm Diseases,Wēn Bìng Tiáo Biàn, 温病条辨)

Formula Applications 1. Essential pattern differentiation Huáng Tŭ Tāng serves as the most common formula used to treat bloody stool or flooding and spotting (bēng lòu) due to spleen yang deficiency. This clinical pattern is marked by:

● light colored blood

● pale tongue with white coating ● deep, thready, and weak pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of spleen yang insufficiency: gastrointestinal bleeding and functional uterine bleeding. 4. Cautions and contraindications Huáng Tŭ Tāng should not be used for bleeding due to blood heat.

Comparison & Contrast Huáng Tŭ Tāng vs. Guī Pí Tāng

Continued

Case Studies Bloody stool Mr. Ding had bloody stool, in which the color of the blood was purple. He also suffered with poor fu-organ function and poor appetite. His was a pattern of distal bleeding. Proximal bleeding is related to the fu-organs, while distal bleeding is related to the zang-organs. The zang-organ refers to the liver and spleen. Blood originates from the heart, but is stored and controlled by the liver and spleen The liver is a resolute viscera and the spleen belongs to the earth of the five elements and yin in the eight principles, therefore liver deficiency generates heat, and heat leads to bleeding. Spleen deficiency produces cold, and cold causes blood to circulate out of the vessels and fail to be stored and controlled and then flow into to

the large intestine, which leads to bloody stool. The method to treat bloody stool was to treat cold by warming, treat heat by clearing, treat the liver deficiency by relieving and moistening, and treat the spleen deficiency by warming and promoting. Huáng Tŭ Tāng from Essentials from the Golden Cabinet is the unique formula that combines fortifying, relieving, warming, and clearing together. Based on its essential function, we used a modified Huáng Tŭ Tāng composed of bái zhú (fried with earth) 1.5 qian, ē jiāo zhū 2 qian, huáng qín (dry-fried) 1.5 qian, zào xīn tŭ (wrapped by hé yè) 4 qian, guăng chén pí 1 qian, zhì gān căo 5 fen, bái sháo (dry-fried) 1.5 qian, fú shén 3 qian, páo jiāng tàn 5 fen, and yuăn zhì 1 qian. Comments: Symptoms of purple bloody stool, poor function of the fuorgans and poor appetite refer to distal bleeding. The location of the disease is in the spleen. Hence, Huáng Tŭ Tāng was used for the treatment. Páo jiāng tàn was used to help tonify the spleen and stanch bleeding. Bái sháo was used to enrich blood and relieve the liver. Fú shén and yuăn zhì are added to calm the mind and tranquilize the spirit. This stems from the theory that calmness generates yin, and can strengthen the effect of stanching bleeding.

Summary There are fourteen formulas within the blood-regulating formulas chapter, divided into two categories:

● formulas that invigorate blood and dissolve stasis ● formulas that stanch bleeding 1. Formulas that invigorate blood and dissolve stasis

This group of prescriptions all shares the function of unblocking blood vessels to remove blood stasis, indicated by unsmooth blood circulation or internal accumulation of stagnant blood. Among them, Táo Hé Chéng Qì Tāng breaks up blood, expels stasis, and clears heat. It is indicated for blood retention in the lower jiao due to the accumulation of blood heat. Xuè Fŭ Zhú Yū Tāng activates blood, removes stasis, circulates qi, and relieves pain. It is indicated for patterns caused by blood stasis and qi stagnation in the chest such as chest pain and headache. Bŭ Yáng Huán Wŭ Tāng tonifies qi, invigorates blood, and unblocks collaterals. It is a commonly used formula for hemiplegia caused by qi deficiency, blood stagnation, and stasis obstructing the collaterals. Fù Yuán Huó Xuè Tāng is indicated for hypochondriac pain due to traumatic injury. Wēn Jīng Tāng and Shēng Huà Tāng are frequently used for gynecological diseases. Wēn Jīng Tāng is good to warm the channels, expel cold, nourish blood, and remove stasis. Its focus is on warming and nourishing rather than expelling, and is a commonly used formula for treating irregular menstruation due to cold patterns caused by deficiency of the chong mai and ren mai and internal obstruction of stagnant blood. Shēng Huà Tāng activates the blood, expels stasis, warms the channels, and relieves pain. It is indicated for inhibited lochia, lower abdominal pain due to cold caused by deficiency, and is a commonly used formula for women to take following childbirth. Shī Xiào Săn circulates the blood, removes stasis, dissipates masses, and stops pain. It is regarded as the fundamental prescription used to treat chest and abdominal pain due to blood stasis. Guì Zhī Fú Líng Wán circulates blood, removes stasis, and slowly and gradually dissipates masses. It is indicated for women with masses in the lower abdomen, spotting menses due to stasis, and threatened miscarriage. 2. Formulas that stanch bleeding

This group of prescriptions shares the function to stop bleeding, and is indicated for patterns of hemorrhage. Shí Huī Săn, Ké Xuè Fāng, Xiăo Jì Yĭn Zĭ, and Huái Huā Săn are prescriptions that cool the blood and stop bleeding. They are indicated for patterns of hemorrhage due to abnormal blood circulation resulting from heat. Shí Huī Săn clears and purges fire, removes stasis, and astringes blood, which strengthens the power to stop bleeding. It is widely used for bleeding in the upper jiao in emergency situations. Ké Xuè Fāng is mainly used to treat hemoptysis caused by liver fire invading the lung by clearing liver fire and dissolving phlegm-heat to treat the root of the disease. Huái Huā Săn and Xiăo Jì Yĭn Zĭ both treat bleeding from the lower jiao. Huái Huā Săn is good to clear the intestines and expel wind. It is indicated for hemafecia due to wind in the large intestine. Xiăo Jì Yĭn Zĭ promotes urination and relieves strangury. It is indicated for blood strangury or bloody urine. Huáng Tŭ Tāng warms yang and fortifies the spleen to contain blood. It is indicated for all sorts of bleeding due to spleen yang deficiency, especially for bloody stool, metrorrhagia, and metrostaxis.

Questions 1.What kind of diseases and symptoms can be treated by the stasisdissolving method or blood-stanching method? How do we prescribe formulas according to pattern differentiation? What is important to observe when applying these formulas? 2.Why are blood-invigorating and stasis-dissolving formulas often associated with qi-circulating or qi-tonifying medicinals? Why are hemostatics often associated with blood-activating and stasis-removing medicinals? Please explain.

3.Which disease is Xuè Fŭ Zhú Yū Tāng indicated for as the representative formula of blood-invigorating and stasis-removing formulas? What are the combination features of Xuè Fŭ Zhú Yū Tāng? 4.What are the differences between Xuè Fŭ Zhú Yū Tāng and Fù Yuán Huó Xuè Tāng in terms of their indications and medicinals? 5.Bŭ Yáng Huán Wŭ Tāng is a blood-invigorating and stasis-dissolving formula, why does it use a heavy dosage of huáng qí as its chief medicinal? 6.Please list the major indications and combination features of Wēn Jīng Tāng. 7.Shēng Huà Tāng is a commonly used prescription for women after childbirth, please state the mechanism of its combination. 8.Both Shí Huī Săn and Ké Xuè Fāng can treat bleeding in the upper jiao, what are the differences between them? 9.Both Huái Huā Săn and Huáng Tŭ Tāng can treat bleeding in the lower jiao, please state their differences in composition and indications.

Endnotes: [1] ⾎在上善忘，⾎在下如狂 [2] 热结膀胱，其⼈如狂也 [3] 不塞不流，不⽌不⾏ [4] 瘀滞不⾏，皆能眩晕 [5] 肝⾜厥阴之脉……是主肝所⽣病者……遗溺闭癃 [6] 肾主⼤便，肝主⼩便 [7] 虚邪偏客于身半，其入深，内居荣卫，荣卫稍衰则真⽓去，邪 ⽓独留，发为偏枯 [8] 因虚致瘀 [9] 奇之不去则偶之，是谓重⽅ [10] 夫从⾼坠下，恶⾎流于内，不分⼗⼆经络，圣⼈俱作风中肝 经，留于胁下，以中风疗之 [11] 女⼦⼆七⽽天癸至，任脉通，太冲脉盛，⽉事以时下 [12] 久视伤⾎，久卧伤⽓，久坐伤⾁，久⽴伤骨，久⾏伤筋，是 谓五劳所伤 [13] 旧⾎不去，则新⾎断不能⽣。⼲⾎痨，⼈皆知其极虚，⽽不 知其补虚正是助病，非治病也，必去其⼲⾎，⽽后新⾎得⽣，乃望回 春 [14] 肠风者，下⾎新鲜，直出四射，皆由便前⽽来……脏毒者， 下⾎瘀晦，无沦便前便后皆然

[15] ⽢苦合⽤，刚柔互济法

CHAPTER 12 Wind-Expelling Formulas Wind-expelling formulas utilize acrid and dispersing wind-expelling medicinals or windexpelling medicinals that extinguish wind and arrest convulsion as their major components. They have the therapeutic actions to scatter and dissipate external wind or calm and extinguish internal wind. Wind-expelling formulas are prescribed to treat wind diseases. Wind diseases cover a wide range of diseases manifested by complicated symptoms. They can be roughly classified into two categories according to their different etiologies:

● external wind patterns ● internal wind patterns External wind patterns include diseases caused by external wind pathogens that have invaded the fleshy exterior, channels and collaterals, sinews, and bones and joints. Tetanus, caused by windtoxin pathogens invading via wounds, also falls into this category. Internal wind patterns refer to wind diseases caused by dysfunctions of the zang-fu organs such as wind produced by extreme heat, wind caused by liver yang, wind due to yin deficiency, and wind due to blood deficiency. Scattering and dissipating external wind and calming and extinguishing internal wind are the treatment methods used to treat wind disease. Wind-expelling formulas are therefore categorized into two types:

● wind-expelling formulas that scatter and dissipate external wind ● wind-expelling formulas that calm and extinguish internal wind The following points concerning the usage of wind-expelling formulas are noteworthy: First, the cause of a wind disease should be differentiated between internal wind and external wind. External wind should be scattered and dissipated instead of being calmed and extinguished, whereas internal wind should be treated in the completely opposite method. Second, both internal and external winds can affect one another and result in a combined disease pattern. In such a case, the main pattern should be identified and the accompanying pattern needs to be also taken into consideration. For instance, in a disease caused by external wind stirring up internal wind, scattering and dissipating will be the main treatment method, and calming and extinguishing wind will be the assisting method. Diseases caused by internal wind that have stirred up external wind are treated by calming and extinguishing as the main treatment method, and scattering and dissipating as the accompanying method. Third, wind-expelling formulas should be combined with other medicinals according to any accompanying pathogens as well as the differentiation between deficiency and excess. For example, wind diseases accompanied by cold, heat, dampness, or blood stasis should be treated with wind-expelling formulas combined with medicinals that dissipate cold, dispel dampness, clear heat, dissolve phlegm, or invigorate blood and dissolve stasis respectively. Last, the medicinals that expel external wind the strongest are acrid, dissipating, warm, and drying in nature and can quickly exhaust qi or injure fluids. Therefore, they should be used cautiously for patients with qi deficiency, fluid consumption, or heat due to yang hyperactivity.

Section 1 Wind-Expelling Formulas that Scatter and Dissipate External Wind Wind-expelling formulas that scatter and dissipate external wind are used for syndromes caused by external wind. The signs and symptoms are headache, aversion to wind, pruritus, numb limbs, spasm and pain of the sinews and bones, and joint dysfunction with bending and stretching; or facial palsy; or limb convulsion and opisthotonos. Common medicinals found within include qiāng huó, dú huó, jīng jiè, fáng fēng, chuān xiōng, and bái zhĭ. Diseases caused by external wind are usually accompanied by other pathogens, and the constitution of the patient may be either deficient or excess. Therefore, formulas should be modified with medicinals that expel cold, clear heat, dispel dampness and phlegm, nourish and invigorate blood, or arrest convulsion according to different conditions. Common formulas in this category are Chuān Xiōng Chá Tiáo Săn, Dà Qín Jiāo Tāng, Xiăo Huó Luò Dān, Qiān Zhèng Săn, Yù Zhēn Săn, and Xiāo Fēng Săn.

Chuān Xiōng Chá Tiáo Săn 川芎茶调散Tea-Mix and Chuanxiong Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind the ingredients into a fine powder. Take 6 g, infused in green tea after meals each time, three times a day. It can also be prepared as a decoction by dosing the medicinals based on their original ratios.

Formula Indications Chuān Xiōng Chá Tiáo Săn is indicated for headaches caused by externally-contracted wind. The symptoms are headache in any part of the head, dizzy vision, and nasal congestion possibly accompanied by aversion to wind and fever. The tongue coating is thin and white, and the pulse is floating.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of externally-contracted wind that has caused a headache. Pathogenic wind attacks the exterior and travels upward along the channels to the head and eyes. There it obstructs the clear yang qi and the flow of qi and blood in the channel, causing a headache, dizzy vision, and nasal congestion. As pathogenic wind may affect different channels, the headache may occur in different parts of the head (frontal, temporal,

occipital, or vertex). Aversion to wind and fever indicate that exterior wind has invaded the exterior. A thin, white tongue coating and a floating pulse are indications of externally-contracted wind. Externally-contracted wind produces the headache. The therapeutic principles used to remedy this pattern are to scatter and dissipate wind in order to relieve pain.

Formula Actions Scatters wind and relieves pain.

Formula Analysis

Continued

Unique Combination Features 1.This formula contains a relatively large number of wind-expelling medicinals that scatter wind and relieve pain. They are medicinals that are ascending and floating in nature, able to reach upward to the vertex of the head. 2.It treats headaches related to multiple channels because it contains various medicinals that affect each of them. 3.Clearing and descending within warming and ascending produces an effect to scatter wind without increasing heat, and to clear and descend while not hindering ascending and scattering.

Further Clarification

What is the significance of the heavy dose of bò he in Chuān Xiōng Chá Tiáo Săn? Wind is a yang pathogen, and therefore easily transforms into heat and dryness. All of the other wind-dispelling medicinals in the formula are acrid and warm and easily create heat and dryness. Bò he in a heavy dose helps scatter wind pathogens and restrict the warm nature of the wind-dispelling medicinals. Its cool nature moderates its action so it can scatter wind without creating heat.

Formula Applications 1. Essential pattern differentiation Chuān Xiōng Chá Tiáo Săn serves as the common formula used to treat headaches caused by externally-contracted wind pathogens. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of headache due to externallycontracted wind: headache resulting from rheum, migraine, cluster headache syndrome, and chronic rhinitis. 4. Cautions and contraindications It is not applicable for patients diagnosed with headache due to internal damage.

Associated Formulas Jú Huā Chá Tiáo Săn (Tea-Mix and Chrysanthemum Powder, 菊花茶 调散) [Source] Continuation of Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă Fù Yú, 丹 溪⼼法附余) [Ingredients]

[Preparation and Administration] Grind the medicinals into a fine powder. Take 2 qian (6 g), infused in green tea after meals each time. [Actions] Scatters wind and relieves pain, and benefits the head and eyes. [Applicable Patterns]

Headache may be caused by externally-contracted wind-heat. Symptoms include: headaches in any part of the head, vertigo, dizzy vision, aversion to wind with fever, a thin, white tongue coating, and a floating, rapid pulse. Both Jú Huā Chá Tiáo Săn and Chuān Xiōng Chá Tiáo Săn have the function to scatter wind and relieve pain and are both used to treat headaches caused by externally-contracted wind. Jú Huā Chá Tiáo Săn is composed by adding jú huā, chán tuì, and jiāng cán to Chuān Xiōng Chá Tiáo Săn. It is focused on scattering and dissipating wind-heat and benefiting the head and eyes. Jú Huā Chá Tiáo Săn is suitable for treating headaches and dizziness caused by externally-contracted wind-heat.

Case Studies Headache Mr. Wang, 35 years old, came to the clinic during the autumn of 1946. He complained of a headache that started after he had caught a wind-cold three months before. The headache would come and go. The previous doctor mistook the pathogenesis for fire flaring up and inappropriately prescribed him with cooling formulas that aggravated his condition causing unstoppable infuriating pain. His pulse was floating with a tight cùn, and his tongue coating was thin and yellow indicating fire constraint due to wind-cold. The head, the confluence of all yang channels, was where the wind pathogen had failed to be relieved at the beginning of the wind-cold. It was then retained by the cooling medicinals causing an obstruction in the channels and collaterals. Clear yang qi was constrained from diffusing freely, and then transformed into rushing up fire. The floating and tight pulse was a sign that windcold was trapped in the exterior. The thin, yellow tongue coating was an

indication of yang constraint transformed into fire. The combination of wind-cold dissipating medicinals with medicinals that diffuse and relieve heat constraint was feasible, but it was not strong enough for this case because of its prolonged course. Therefore, it was used in conjunction with external treatments to strengthen its effect. Prescription for oral administration: Chuān xiōng 2 qian, bái zhĭ 2 qian, shēng jiāng 2 slices, bò he 2 qian, qiāng huó 1 qian, jú huā 2 qian, fáng fēng 1 qian, chăo huáng qín 1 qian, chén chá 2 qian. Prescription for external treatment: Cán shā 100 g, after being decocted in fresh water until the water had been nearly evaporated, was put on a clean cloth to dress the painful focal points. The dressing was changed once every day. The patient was cured with ten doses of the formula and a half-month of external treatment.1 Comments: Analyzing this headache case, both the etiology and the floating, tight pulse are indications of an externally-contracted wind-cold. The refractory headache and thin, yellow tongue coating are obviously caused by fire that transformed from the constrained clear yang qi caused by the prolonged obstruction of wind-cold. Therefore, Chuān Xiōng Chá Tiáo Săn modified by removing jīng jiè and xì xīn and adding jú huā, huáng qín, and shēng jiāng was used to scatter and dissipate wind-cold, as well as to diffuse heat constraint. External application of cán shā strengthens the orally administered formula to achieve a faster effect with its action to relieve pain by expelling wind and unblocking the collaterals.

Dà Qín Jiāo Tāng ⼤秦艽汤Large Gentian Decoction Source Text Collection of Writings on the Mechanism of Disease, Suitability of Qi, and the Safeguarding of Life as Discussed in the ‘Basic Questions’ (Sù Wèn Bìng Jī Qì Yí Băo Mìng Jí, 素问病机⽓宜保命集)

Formula Ingredients

1 Li Ji-chang Cases Compiling Group. Li Ji-chang’s Medical Cases 李继昌医案. Kunming: Yunnan People’s Press; 1978.

Preparation and Administration

Prepare Dà Qín Jiāo Tāng as a decoction for oral use with an appropriate reduction in dosage.

Formula Indications Dà Qín Jiāo Tāng is indicated for an early stage of a wind attacking the channels and collaterals pattern. The symptoms are deviation of the eyes and mouth, difficulty in speaking due to stiff tongue, an inability to move the extremities, often accompanied by aversion to cold with fever, spasms and tension of the extremities, a white or yellow tongue coating, and a superficial, rapid pulse or wiry, thin pulse.

Analysis of Fundamental Pattern Pathogenesis This formula treats wind-strike caused by wind pathogens striking the channels and collaterals. When wind strikes a person with insufficient zheng qi and deficiency of the ying-blood and channels, it leads to obstruction of qi and blood and blockage of channels. In addition, insufficient blood fails to nourish the sinews causing atrophy and weakness of the sinews and muscles. The result is deviation of the eyes and mouth, difficulty in speaking due to a stiff tongue, and an inability to move the extremities. Invasion of the exterior by pathogenic wind manifests an aversion to cold, fever, and a floating pulse. The primary treatment is to dispel wind and scatter pathogens, along with nourishing and invigorating blood to unblock the collaterals.

Formula Actions Scatters wind and clears heat, nourishes and invigorates blood.

Formula Analysis

Unique Combination Features 1.Wind-dispelling medicinals are combined with medicinals that nourish blood and boost qi in order to simultaneously treat zheng qi and pathogenic wind by scattering and nourishing methods. 2.Extinguishing wind is achieved by treating blood because normal blood circulation facilitates the disappearance of wind. 3.Heat is cleared while wind is scattered by preventing the tendency of wind to transform into heat as well as suppress the warm and dry nature of wind-dispersing medicinals.

Further Clarification 1. The significance of medicinals that supplement and invigorate the blood First, deficient blood fails to nourish the tendons and muscles; therefore, the limbs are too weak to move, and the tongue is too stiff to

pronounce. Supplementing the blood enables it to nourish the tendons. Second, blood deficiency typically results in blood stasis within the vessels; meanwhile wind attacking the channels and collaterals worsens the case by causing stasis in the channels and collaterals. Therefore, medicinals that supplement and invigorate blood are used to facilitate blood circulation; thereafter, the wind is easier to dissipate for it has no place to linger. This is the significance of “extinguishing wind is achieved by treating blood because normal blood circulation facilitates the disappearance of wind”[1]. Finally, wind-dispersing medicinals are dry enough to damage yin-blood, therefore blood-supplementing medicinals are combined to ameliorate the warm and dry nature of wind-dispersing medicinals. 2. The significance of using heat-clearing medicinals within the formula On one hand, as a yang pathogen, wind tends to generate heat and dryness. On the other hand, wind-dispersing medicinals usually have a warm and dry nature. Therefore, heat-clearing medicinals are used to prevent wind from generating heat as well as to ameliorate the warm and dry nature of the wind-dispersing medicinals. 3. The significance of using qi-boosting and spleen-fortifying medicinals within the formula The spleen governs the four limbs and the muscles; meanwhile, it is also the source of qi and blood production. Medicinals that boost qi and fortify the spleen are not only used to reinforce the source of qi and blood production, but also assist blood-nourishing medicinals to reinforce the zheng qi.

Formula Applications 1. Essential pattern differentiation

Dà Qín Jiāo Tāng serves as the common formula used in the early stages of wind striking the channels and collaterals. This clinical pattern is marked by:

2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of sluggish speech and hemiplegia: cerebral angiospasm and cerebral thrombosis; when the patient shows signs of the early stage of wind striking the channels and collateral: facial palsy; when the patient shows signs of heat bì due to wind-damp: rheumatoid arthritis. 4. Cautions and contraindications This formula should not be used for patients with internal wind.

Case Studies

Bì syndrome Mr. Zhao, 32 years old, came to the clinic on March 16th, 1972 after suffering for more than one year. Initially, he felt aching, heaviness, and weakness in both lower limbs from the coccyx to the feet. Over the last six months the pain grew worse and disabled him from walking. There were no red, swollen, hot joints detected. The patient had yellow urine, burning palms, a red tongue body with a thin, dry coating, and a deep, slippery, powerful pulse. He had been diagnosed with “lumbosacral radiculitis” but has not had a satisfactory response to the integrative treatments in the hospital. He was prescribed cold-expelling medicinals and medicated wine prepared with tiger bones, which unexpectedly aggravated the pain. A comprehensive analysis of the pulse and symptoms concluded that his problem was caused by internal heat produced from blood deficiency that had failed to nourish the sinews, along with wind, cold, and dampness invading the exterior. In the end, it progressed into a bì syndrome. The treatment was to nourish blood and clear heat, scatter wind and unblock the collaterals. He was prescribed Dà Qín Jiāo Tāng. Prescription: Qín jiāo 15 g, qiāng huó 10 g, dú huó 10 g, fáng fēng 10 g, chuān xiōng 10 g, bái zhĭ 15 g, huáng qín 15 g, xì xīn 5 g, shēng dì huáng 20 g, shú dì huáng 20 g, shēng shí gāo 30 g, dāng guī 15 g, chì sháo 15 g, fú líng 15 g, cāng zhú 15 g. Decocted in water for oral administration, twice per day, three doses. The second visit was on March 20th: The patient’s pain was dramatically alleviated and he was able to walk slowly with pain radiating to the waist and coccyx. He was prescribed the same formula, modified. Prescription: Qín jiāo 15 g, qiāng huó 10 g, dú huó 10 g, fáng fēng 10 g, chuān xiōng 10 g, huáng qín 15 g, shēng dì huáng 20 g, shú dì huáng 20

g, shēng shí gāo 30 g, dāng guī 5 g, chì sháo 15 g, cāng zhú 15 g, chuān shān lóng 50 g, léi gōng téng 50 g. The administration method was the same as the previous formula. The third visit was on March 26th: After taking three doses of the previous prescription, the pain was relieved in both lower limbs and dramatically alleviated in the coccyx. The patient was able to walk despite the slight aching pain. He had slight yellowish urine, a thinner tongue coating, a redder and moister tongue body, and a deep, slippery, moderate pulse. The same formula was prescribed for another four doses. The fourth visit was on April 20th: The pain in the lower limbs radiating to the coccyx was gone, except that the patient still had slight aching pain after walking for a long distance. The same formula was continued for several more doses in order to strengthen the efficacy. 1 Comments: In this case, the aching pain, heaviness, and weakness without red, swollen, or hot joints were due to the initial stage of bì syndrome. However, the yellow urine, burning palms, thin, dry red tongue, and deep, slippery, powerful pulse were caused by blood deficiency and an internal heat constitution attacked by wind, cold, and dampness invading the muscles, sinews, bones, channels, and collaterals. The result was obstruction preventing qi and blood in the channels and collaterals from nourishing the muscles and sinews. Correspondingly, Dà Qín Jiāo Tāng was prescribed with added cāng zhú and bái sháo replaced by chì sháo to scatter wind, dissipate cold, and expel dampness externally, as well as, nourish blood and clear heat internally to achieve a satisfactory effect. As soon as the pain was relieved, xì xīn and bái zhĭ were taken out to prevent their acrid-warm and dry nature from damaging yin. Chuān shān lóng and léi gōng téng were added to strengthen the efficacy by clearing heat, unblocking collaterals, and relieving pain. Dà Qín Jiāo Tāng, a formula designed for acute hemiplegia

caused by pathogenic wind attacking the body, can also be used for the bì syndrome caused by heat due to blood deficiency and externally-contracted wind, cold, and dampness pathogens.

Xiăo Huó Luò Dān ⼩活络丹Minor ChannelActivating Elixir a.k.a. Huó Luò Dān (活络丹) Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration 1 Ke Li-min. Selected Cases of Experienced TCM Doctors ⽼中医医案选.. Harbin: Heilongjiang Science and Technic Press; 1981.

Grind the medicinals into a powder and form into pills with honey. Take 3 g twice a day with mellow liquor or warm boiled water. This formula may also be prepared as a decoction for oral use with an appropriate reduction in dosage. Chuān wū and căo wū should be cooked 30 minutes prior to the other medicinals.

Formula Indications

1. Bì syndrome due to wind, cold, and dampness characterized by pain, numbness, and spasms of the limbs, body and sinews, dysfunction with bending and stretching the joints, wandering pain, a pale purple tongue body with a white tongue coating, and a deep, wiry or choppy pulse. 2.Wind-strike due to dampness, phlegm, and blood stasis obstructing the collaterals characterized by persistent numbness and weakness of the limbs, heavy sensation in the waist and legs, or pains in the legs and arms, etc.

Analysis of Fundamental Pattern Pathogenesis This formula treats the bì syndrome caused by wind-cold-dampness, static blood, and phlegm turbidity obstructing the channels. Wind-colddampness persistently obstructs the channels and collaterals. This leads to the obstruction of qi and blood, inhibition of ying and wei movement, fluids coagulating into phlegm, and blood blockage forming static blood. Windcold-dampness combines with phlegm and static blood to cause an obstruction of the channels and collaterals, resulting in painful numb spasms, whole body muscle and sinews tightness and flexion-extension dysfunction; persistent numbness due to wind-strike, heaviness of waist and legs, or painful legs and arms. The treatment is to dispel wind and dissipate cold, and dissolve phlegm and invigorate blood.

Formula Actions Dispels wind and eliminates dampness, dissolves phlegm to unblock the collaterals, and invigorates blood to relieve pain.

Formula Analysis

Unique Combination Features Medicinals that dissipate wind and cold and eliminate dampness are combined with those that resolve phlegm and invigorate blood in order to treat both root and branch simultaneously. Xiăo Huó Luò Dān specializes in relieving pain with its heavy dosage and strong effect.

Further Clarification The significance of making medicinals into pills: “Pills are gentle in nature.” The medicinals of a formula are made into pills in order to function gently. The enduring stagnation of heat, dampness, phlegm, and blood stasis in the channels and collaterals need to be hunted down and expelled by strong medicinals. However, these medicinals should not work too

drastically; otherwise zheng qi might be damaged, which would make it more difficult to expel the pathogens. If the zheng qi is damaged, the pathogens become stronger. That is why in a case like this, gentle reducing works better. The theory behind using this formula as a pill “treats the pathogens with drastic medicinals, but does it in a gentle manner.”[2] Although pills are the ideal preparation, this formula can also be made into decoction.

Formula Applications 1. Essential pattern differentiation Xiăo Huó Luò Dān serves as the common formula used to treat wind, dampness, obstinate phlegm, and blood stasis stagnating in channels and collaterals. This clinical pattern is marked by:

● spasm and pain of the limbs and sinews ● inability for the joints to stretch properly ● pale, purple tongue body with white tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of wind-dampness, phlegm, and blood stasis stagnating in the channels and collaterals: chronic rheumatic

arthritis, rheumatoid arthritis, hyperostosis, sciatica, and scapulohumeral periarthritis. 4. Cautions and contraindications This formula is forbidden to use in patients with heat bì due to winddampness and heat due to yin deficiency. It should be used cautiously in the weak and the pregnant. Chuān wū and căo wū should not be used in large doses to prevent their toxins from harming the body.

Associated Formulas Dà Huó Luò Dān (Great Channel-Activating Elixir, ⼤活络丹) [Source] Medical Standards of the Han Dynasty (Lán Tái Guĭ Fàn, 兰台轨范) [Ingredients]

[Preparation and Administration] Grind these fifty medicinals in to powder and form into pills the size of a longan seed using honey (wrapped with gold foil). Take 1 pill once daily with aged wine. [Actions] Dispels wind-dampness, boosts qi and blood, and unblocks the channels to relieve pain. [Applicable Patterns] Wind, dampness, phlegm, and static blood obstructing the channels and collaterals. Symptoms include: paralysis due to stroke accompanied by zheng qi deficiency, wĕi and bì syndrome, yin abscesses, multiple abscesses and wounds.

Xiăo Huó Luò Dān resembles Dà Huó Luò Dān in its actions and indications. However, the latter treats both the branch and root by dispelling wind, eliminating dampness, warming the interior, and reinforcing zheng qi by boosting qi, nourishing blood, enriching yin, and assisting yang; therefore it can be applied for patients with excessive pathogens and deficient zheng qi. In contrast, Xiăo Huó Luò Dān is designed to expel pathogens from patients who have excessive pathogens and healthy zheng qi by dispelling wind, eliminating dampness, dissolving phlegm, and invigorating blood.

Case Studies Bì syndrome A 48-year-old patient had a wiry and powerful pulse, pain and swelling on the right ankle and lower leg which were slightly relieved by warmth and massage. The syndrome was caused by wind, cold, and dampness invading the channels, which needed to be treated by diffusing the channel qi. He was prescribed one Xiăo Huó Luò Dān pill to be swallowed with aged wine. 1 1 Ye Tian-shi. Case Records As A Guide to Clinical Practice 临证指南医案. Shanghai: Shanghai Scientific and Technical Publishers; 1959.

Comments: Swollen, painful joints alleviated by warmth and massage, and a wiry and forceful pulse were caused by blood stasis in the collaterals and inhibited ying and wei due to wind, cold, and dampness invading collaterals. Xiăo Huó Luò Dān was used to expel wind, cold, and dampness and dissolve stasis to unblock collaterals. When it is swallowed with wine, the actions of moving blood and unblocking collaterals are strengthened.

Qiān Zhèng Săn 牵正散Symmetry-Correcting Powder Source Text Secret Formulas of the Yang Family (Yáng Shì Jiā Cáng Fāng, 杨氏家 藏⽅)

Ingredients

Preparation and Administration Grind the ingredients into a fine powder. Take 3 g each time with warm wine any time during the day. This formula may also be prepared as a decoction with the appropriate dosages.

Formula Indications Qiān Zhèng Săn is indicated for wind attacking the channels and collaterals on the head and face characterized by deviation of the mouth and eyes, facial muscle twitch, and a light red tongue body with a white tongue coating.

Analysis of Fundamental Pattern Pathogenesis

This is a pattern caused by wind-phlegm blocking the channels and collaterals in the face and head. Patients with a constitution of phlegm turbidity stored in the yangming are attacked by exterior wind at the yangming channel. Wind-phlegm blocking the channels and collaterals on the face and head cause channel stagnation, tendon and muscle malnourishment, then atony. The slackened muscles are pulled by the tense, so there is facial palsy. Excessive wind leads to mobility, so there is spasm in facial muscles. Dispelling wind and dissolving phlegm, unblocking the collaterals, and arresting convulsions should treat wind-phlegm blocking the channels and collaterals.

Formula Actions Dispels wind and dissolves phlegm, unblocks the collaterals and arrests convulsion.

Formula Analysis

Continued

Unique Combination Features

Medicinals that dispel wind and dissolve phlegm are combined with those that trace down wind and unblock the collaterals. This formula uses simple medicinals to achieve a remarkable effect.

Formula Applications 1. Essential pattern differentiation Qiān Zhèng Săn serves as the common formula used to treat windphlegm obstructing the head and face. This clinical pattern is marked by:

● sudden onset of facial palsy ● pale tongue body with white tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of wind-phlegm blocking the channels and collaterals of the face and head: facial palsy, trigeminal neuralgia, or migraine. 4. Cautions and contraindications This formula should not be used to treat facial palsy or hemiplegia due to qi deficiency and blood stasis or internal stirring of liver wind. Bái fù zĭ and quán xiē should not be used in excessive dosages, as they have toxicity.

Associated Formulas Zhĭ Jìng Săn (Spasm-Relieving Powder, ⽌痉散) [Source] TCM Therapy for Epidemic Type B Encephalitis (Liú Xíng Xìng Yĭ Xing Năo Yán Zhōng Yī Zhì Liáo Fă, 流⾏性⼄型脑炎中医治疗法) [Ingredients]

[Preparation and Administration] Grind the medicinals into a fine powder. Take 1 fen (0.3 g) for one-yearold baby. [Actions] Dispels wind and arrests convulsions, unblocks the collaterals and relieves pain. [Applicable Patterns] Incessant convulsions due to type B encephalitis. Convulsive syncope and limb spasm caused by other diseases, refractory headache, migraine or arthralgia. Zhĭ Jìng Săn and Qiān Zhèng Săn both contain quán xiē to dispel wind and arrest convulsions. Zhĭ Jìng Săn is effective for arresting convulsions and relieving pain because it contains wú gōng; therefore it is applicable to convulsive syncope due to internal stirring of liver wind and refractory pain. Containing bái fù zĭ and jiāng cán, Qiān Zhèng Săn specializes in dispelling

wind and dissolving phlegm, so it is applicable to facial palsy due to windphlegm blocking the collaterals.

Case Studies Wind attacking the facial channels and collaterals Case #1: On a hot summer day Ms. Zhang, 27 years old, took a coach home. During the ride, in order to cool off, she faced an open window through which a strong wind blew on her face. By the time she arrived home she felt her facial muscles on the left side spasm and deviate. On clinical inspection, the tongue coating was white and moist, and her pulse was floating. The syndrome was differentiated as wind attacking the yangming channel causing areas of excessive relaxation to pull toward those of hypertonicity. The therapeutic method was to scatter pathogenic wind in the yangming channel and relieve spasm. Prescription: Guì zhī 9 g, bái sháo 9 g, shēng jiāng 9 g, dà zăo 12 g, zhì gān căo 6 g, gé gēn 15 g, bái fù zĭ 6 g and quán xiē 6 g. 1 Comments: The patient developed a facial spasm and palsy after facing a strong wind. Her white moist tongue coating and floating pulse justified the pathogenesis as wind pathogen attacking yangming channel where phlegmturbidity coagulated and obstructed. She was prescribed Guì Zhī Jiā Gé Gēn Tāng modified with Qiān Zhèng Săn to dispel wind, dissolve phlegm, and unblock the collaterals to arrest convulsion. In this formula, guì zhī was effective for warming and unblocking the channels, gé gēn promoted fluid production, relaxed the sinews, and relieved spasms, and bái sháo nourished yin and relieved spasms; thereby, the curative effect was achieved. Case #2: Mr. Li, who was a teacher, came to the clinic for the first time on November 7th, 1979. His chief complaint was facial palsy for seven days.

Before the palsy appeared, he would often feel numbness and discomfort on his face, he then found his nose-labial groove turning flat, mouth and eyes deviating to the left, and numb right cheek. He had a wiry pulse and a thin coating. In this case, the therapeutic method was to boost qi and harmonize blood, as well as, suppress convulsions and extinguish wind. Prescription: Shēng huáng qí 24 g, dāng guī 18 g, qiāng huó 9 g, dú huó 9 g, quán xiē 6 g, wú gōng 2 slices. The second visit on November 7th: After taking the previous prescription for four days, the patient felt the numbness in the face was alleviated. In order to treat pathogenic wind invading the channels and collaterals, modified Qiān Zhèng Săn would be prescribed continuously. Prescription: Bái fù zĭ 9 g, jiāng cán 6 g, quán xiē 6 g, huáng qí 20 g, dāng guī 10 g. He was advised to take five doses. The third visit: The facial palsy was gone, but the numbness was still there. Bā Zhēn Tāng was used to regulate and supplement his weak body.2 1 Chen Ming. Liu Du-zhou Selected Case Records of Clinical Practice 刘渡⾈临证验案精 选.Beijing: Academy Press; 1996. 2 Compiled by Gansu People’s Publishing House. The Collections of Consilia and Medical Professional Essay of Chinese Medicine 中医医案医话集锦. Xi’ning: Gansu People's Publishing House; 1981.

Comments: In this case, the patient had a constitution that was deficient of qi and blood as well as empty vessels and collaterals that stored phlegm turbidity. His facial channels and collaterals were attacked by pathogenic wind that caused wind-phlegm to obstruct the collaterals. His facial muscles could not receive nourishment because of the obstruction. Therefore, the facial numbness and palsy occurred. At first a formula that boosted qi, supplemented blood, dispelled wind, unblocked collaterals, and arrested convulsions was administrated. It improved the condition to some extent but

it did not dissolve the phlegm. Therefore the prescription was changed to Qiān Zhèng Săn combined with Dāng Guī Bŭ Xuè Tāng to dispel wind and dissolve phlegm, unblock the collaterals and arrest convulsion, as well as boost qi and harmonize blood. With this formula combination targeting both the root and the branch, the deviated mouth and eyes were corrected to the right place. Numbness, a sign of qi and blood deficiency, was finally relieved by Bā Zhēn Tāng, which boosted qi and supplemented blood to rehabilitate the ill body.

Yù Zhēn Săn ⽟真散True Jade Powder Source Text Orthodox Lineage of External Medicine (Wài Kē Zhèng Zōng, 外科正 宗)

Formula Ingredients

Preparation and Administration Grind equal amounts of the medicinals into powder. For internal use, take 6 g three times daily with warm liquor. In cases of lockjaw and opisthotonus, the source text advises to administer 9 g three times daily with warm urine from an infant. When applying it topically, apply a moderate dosage to the affected area. This formula may also be prepared as a decoction with appropriate dosages.

Formula Indications Yù Zhēn Săn is indicated for tetanus. The symptoms are lockjaw, tightly-closed mouth and lips, stiff body, opisthotonus, and a wiry, tight

pulse; there could even be gnashed teeth and a contracted tongue.

Analysis of Fundamental Pattern Pathogenesis Tetanus is caused by wind-toxins invading the channels through an area of the body that has been broken causing fluid accumulation which transforms into phlegm. Excessive wind induces mobility; exterior wind provokes interior wind and causes symptoms such as lockjaw, tightly-closed mouth and lips, stiff body, and opisthotonus. The therapeutic principles used to remedy this pattern are to dispel wind and dissolve phlegm, relieve spasm and arrest convulsion.

Formula Actions Dispels wind and dissolves phlegm, relieves spasms and arrests convulsion.

Formula Analysis

Unique Combination Features This formula combines the method of dissipating wind, which is the principle method, with the method of dissolving phlegm and arresting convulsion. The formula’s ability to arrest convulsions is achieved by dissipating wind. This formula works by treating both the branch and root of the disease. This formula is a modification of Yù Zhēn Săn recorded in Experiential Formulas for Universal Relief (Pŭ Jì Bĕn Shì Fāng, 普济本事⽅). It is composed of tiān nán xīng and fáng fēng and is indicated only for tetanus. On the basis of the former formula, Orthodox Lineage of External Medicine (Wài Kē Zhèng Zōng, 外科正宗) added bái fù zĭ, qiāng huó, bái zhĭ, and tiān má; here the actions of dispelling wind, dissolving phlegm, and relieving spasms are stronger than the former formula.

Further Clarification This is a formula for tetanus, which is a disease caused by exterior wind. Why is tiān má, a medicinal that calms the liver and extinguishes wind used? It is because the liver, an organ of wind and wood is connected by qi with wind. Excessive wind induces mobility; therefore exterior wind provokes liver wind. This induces convulsions, a symptom caused by stirring of the liver wind internally. Therefore, acrid medicinals that scatter exterior wind are combined with tiān má to treat the branch and extinguish wind and arrest convulsions.

Formula Applications 1. Essential pattern differentiation

Yù Zhēn Săn serves as the common formula used to treat tetanus. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of pathogenic wind attacking the channels and collaterals: tetanus, facial palsy, and trigeminal neuralgia. 4. Cautions and contraindications This formula should not be applicable to tetanus patients who are diagnosed with deficiency of qi and fluid. It is forbidden to use for patients with excessive heat generating wind in the liver channel. Bái fù zĭ and tiān nán xīng should be dosed cautiously because of their toxicity in nature. It cannot be used in pregnant women.

Case Studies Tetanus Case #1: A 32-year-old man had a rusty nail poke in his left sole about 1.5 cm deep, without much bleeding. On the third day, he felt it was hard to masticate and swallow and suffered one episode of spasm. On the fourth day,

the length of the spasms increased and began to include spasticity of his neck and lumbar vertebra, his body temperature rose to 39.6 ℃, he had a high pulse rate, and the wound was swollen and hard. A thick layer of Yù Zhēn Săn was applied on the wound with gauze and bound with a bandage. In addition, a 3 qian package of powder was given to him every three hours with warm yellow rice wine. The next day, the length of the spasms was obviously decreased. On the third day of treatment, the swollen, hard wound was completely softened and recovered, and swallowing normalized. After twelve days of treatment, the patient completely recovered. 1 Comments: The patient in this case had a wound that was swollen and hard, and the limbs and body muscles were spastic and convulsing because of injury. These symptoms are indications of tetanus due to wind-toxins invading channels through the wound. Yù Zhēn Săn is an effective formula to treat tetanus. Therefore, the outstanding curative effect it offers is increased when both internal and external treatments are applied. Case #2: Mr. Chen, 40 years old, had his right middle finger broken by a machine which caused him bleeding ten days prior to his visit. After immediate application of external medicine, the wound healed. However three days later, he found it difficult to open his mouth followed by periodic spasms that, at first, occurred more than ten times per night but later occurred once every several minutes. When he turned to me, he had a stiff waist, tight abdomen, forced smile, sweating, coughing, and spiting white sputum. These were all clear symptoms of tetanus. 1 Zhang Jue-ren. The Effect of Yù Zhēn Săn in the Treatment of Tetanus ⽟真散治疗破伤风的疗 效. Journal of Traditional Chinese Medicine.1956; (8): 421.

Prescription: Yù Zhēn Săn 4 qian, infused with water and taken twice: gōu téng 3 qian, zhū shā 8 fen (infused in water), tiān má 2 qian, qián hú 2 qian, jú hóng 1.5 qian, jié gĕng 1 qian, and gān căo 1 qian decocted with

water. He took two doses in a row and had acupuncture as auxiliary treatment. The acupuncture point selection included DU 20 (băi huì), DU 14 (dà zhuī), BL 13 (fèi shù), ST 6 (jiá chē), BL 60 (kūn lún), and BL 57 (chéng shān). Strong stimulation was applied on these points. After taking the medicinals and acupuncture, the patient had his symptoms greatly alleviated. The condition continued to improve as the aforementioned formula was taken. After taking supplementary and nourishing medicinals, the patient nearly recovered.1 Comments: After the patient’s skin and flesh were wounded, he developed lockjaw, spasms, and convulsions, which are symptoms of tetanus. Therefore, Yù Zhēn Săn was applied topically to dispel wind, dissolve phlegm, and arrest convulsions. In addition, a decoction of Yù Zhēn Săn was also adopted to calm the liver, extinguish wind, arrest convulsions, diffuse the lung, and dispel phlegm. Tetanus is an emergent and severe condition, so acupuncture was also adopted as auxiliary treatment to strengthen the effect of the treatment.

Xiāo Fēng Săn 消风散Wind-Dispersing Powder Source Text Orthodox Lineage of External Medicine (Wài Kē Zhèng Zōng, 外科正 宗)

Formula Ingredients

1 Zhou Ding-yang. The Clinical Selection of TCM External Medicine 中医外科临床选辑. Nanchang: Jiangxi People’s Publishing House; 1964.

Preparation and Administration Prepare as a decoction.

Formula Indications

Xiāo Fēng Săn is indicated for rubella and eczema. The symptoms are itching skin, red rashes that affect a large part of the body, fluids that leak upon scratching, a white or yellow tongue coating, and a superficial, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This formula treats rubella and eczema caused by wind-heat or winddampness trapped between the skin, striae, and interstices. Wind, dampness, and heat invade the body and settle in the blood vessels where it is unable to vent externally or drain internally. The symptoms are itching skin, red rashes, fluids that leak upon scratching. The appropriate treatment is to scatter wind, clear heat, and eliminate dampness; scattering wind is the primary method and clearing heat and eliminating dampness are secondary.

Formula Actions Scatters wind and eliminates dampness, clears heat and nourishes the blood.

Formula Analysis

Unique Combination Features First, this formula primarily dispels wind; it also eliminates dampness and clears heat. When the scattering method is combined with the clearing and draining methods, wind, dampness, and heat will all be addressed in one strike. Second, blood is treated at the same time that wind is treated because the normal circulation blood facilitates the disappearance of wind.

Formula Applications 1. Essential pattern differentiation Xiāo Fēng Săn serves as the common formula used to treat rubella and eczema. This clinical pattern is marked by:

● pruritus

● red measles ● floating pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of wind-heat or winddamp patterns: acute urticaria, eczema, allergic dermatitis, paddy field dermatitis, drug-induced dermatitis, and neurodermatitis. 4. Cautions and contraindications This formula should not be used to treat rubella due to deficient cold. During the course of treatment, patients are forbidden to take spicy, seafood, cigarettes, wine, or strong tea to ensure good efficacy.

Associated Formulas Dāng Guī Yĭn Zĭ (Chinese Angelica Drink, 当归饮⼦) [Source] Formulas to Aid the Living (Jì Shēng Fāng, 济⽣⽅) [Ingredients]

[Preparation and Administration] Cut the medicinals into pieces. One doge is 4 qian (12 g). Add 1.5 zhan of water and decoct it with 5 pieces of shēng jiāng until 80% water remain, remove the dregs and take it warm. [Actions] Nourishes and invigorates blood, scatters wind and relieves itching. [Applicable Patterns] Rubella and eczema due to blood deficiency and heat or pathogenic wind attacking the exterior. Symptoms include: itchy or dry skin, pale red measles, a pale tongue with a white coating, and a floating and thready pulse. Dāng Guī Yĭn Zĭ and Xiāo Fēng Săn both have the actions of nourishing and harmonizing blood, as well as scattering wind to relieve itching. The two formulas are both applicable to rubella and eczema. Xiāo Fēng Săn specializes in scattering wind, clearing heat, and eliminating dampness to dispel pathogens. Therefore, it is effective for rubella and eczema due to wind, dampness, and heat constraint in the skin. In this pattern the pathogens are excessive and the zheng qi is sufficient. Dāng Guī Yĭn Zĭ specializes in nourishing blood and harmonizing ying. It is applicable to rubella and eczema due to ying-blood deficiency and wind retention in the skin. In this pattern zheng qi is deficient while the pathogens are excessive.

Case Studies

Eczema Ms. Shi, a 47-year-old staff of the Zhangjiakou City police station, had her initial visit on May 17th , 1978. She presented with a rash that has been on her face and hands for 28 years. Every year the rash became more serious during the windy, humid season from April to August. The condition varied with time and there was also occasional photophobia. After many failures with both internal and external treatments, she came to me seeking treatment. Her complexion was red, and the pruritus was so serious that her sleep was affected. Yellow pus was discharged when the rash began to rupture. The fissure was as painful as a needle agitating it, and she was restless once the rashes became scabbed. Whenever the wind blew, the pruritus would exacerbate; when it was most severe she would have facial edema. Her tongue body was light red with a yellow greasy coating, and her pulse was deep, thready, and weak. The pulse and symptoms indicated that the disease was caused by interior retention of damp-heat and wind generated by blood deficiency. The treatment method to be adopted was to dispel wind, dry dampness, clear heat, and harmonize blood. The prescription used was Xiāo Fēng Săn with additions: jīng jiè 12 g, fáng fēng 3 g, dāng guī 9 g, kŭ shēn 12 g, niú bàng zĭ 12 g, cāng zhú 12 g, shēng dì 30 g, chán tuì 18 g, zhī mŭ 6 g, shí gāo 18 g, má rén 9 g, mù tōng 12 g, bàn xià 9 g, gān căo 6 g, bái jí lí 12 g, and tŭ fú líng 30 g. One package, decocted with water, per day. Second visit on May 23th: After taking five doses, the patient felt that the itching was more severe. This was caused by the medicinals effecting at the location of the disease and inducing a struggle between healthy and pathogenic qi. Also, her pulse remained unchanged. Bái jí lí was removed from the previous prescription and mài dōng 30 g and chán tuì 30 g were added in order to dissipate wind-heat.

Third visit on May 27th: After four doses of the revised formula had been taken, the condition improved significantly. The scab began to strip and itching began to decrease. Bàn xià was removed from the prescription and eight more dosages were dispensed. Fourth visit on June 5th: The eczema on the face was almost gone, however the pruritus was aggravated when she encountered wind and heat. Recently she had dry stools and a deep moderate pulse. Therefore, the previous formula was modified: jīng jiè 12 g, fáng fēng 9 g, dāng guī 9 g, shēng dì 30 g, kŭ shēn 12 g, niú bàng zĭ 12 g, cāng zhú 12 g, chán tuì 30 g, zhī mŭ 6 g, mù tōng 9 g, shí gāo 15 g, má rén 24 g, mài dōng 30 g, sāng bái pí 9 g, and gān căo 3 g. One package per day was to be taken, decocted in water. Fifth visit on June 10th: After four doses of the recent formula had been taken, all of her symptoms disappeared. Four more doses of the same formula were dispensed in order to consolidate the effect. 1 1 Compiling Committee of Hebei Traditional Chinese Medicine Case Studies. Hebei Traditional Chinese Medicine Case Studies 河北中医验案选. Shijiazhuang: Hebei People’s Press; 1982.

Comments: This was a case of wind-dampness and pathogenic heat constrained within the muscle layer and interstitial space causing a stubborn skin problem. The case was enduring and reactive to seasonal changes in the environment. Chronic constraint produced dryness, which exhausted yin and blood. Internal wind was generated from yin and blood damage and it coexisted with external wind. Xiāo Fēng Săn was adopted to scatter wind, dispel dampness, clear heat, and harmonize blood. Bàn xià was added to harmonize the stomach and dry dampness. Bái jí lí was added to dispel wind and relieve itching. Tŭ fú líng was added to drain dampness and relieve itching. The treatment progressed and on the second visit bái jí lí was removed and mài dōng was added to enrich yin and moisten dryness. The

dosage of chán tuì was increased to strengthen the effect of dispelling wind and relieving itching. On the third visit, her symptoms were greatly improved. Since there is a warm drying aspect of bàn xià, it was removed from the formula for fear of it damaging yin. Yin deficiency and blood dryness can produce wind; therefore, medicinals that enrich yin and nourish blood were added to Xiāo Fēng Săn at a large dosage. This modification conforms to the principle “treating blood before treating wind, and the wind will disperse automatically when the blood moves". The lung governs the skin and body hair, so sāng bái pí was added to clear and discharge lung heat in order to cure this chronic disease.

Section 2 Wind-Expelling Formulas that Calm and Extinguish Internal Wind Wind-expelling formulas that calm and extinguish internal wind are applicable to diseases due to internal wind, or the syndromes described by the Basic Questions as “all wind with shaking and vertigo is ascribed to the liver”[3]. Internal wind diseases can be differentiated into deficient and excess categories according to their pathomechanisms. The excess syndrome of internal wind results from hyperactive yang generating wind. The associated symptoms are refractory high fever, spasms and convulsive syncope due to excessive heat in the liver channel; or hyperactive liver yang harassing the upper body manifest by vertigo, drunklike flush, sudden fainting and unconsciousness, facial palsy, and hemiplegia. The therapeutic method used to treat this syndrome is calming the liver and extinguishing wind. Common medicinals used to calm the liver and extinguish wind are líng yáng jiăo, gōu téng, tiān má, shí jué míng, dài zhĕ shí, lóng gŭ, and mŭ lì. In addition, when hyperactive yang due to excessive heat scorches fluids or concentrates fluids into phlegm, medicinals that clear heat, nourish yin, and dissolve phlegm may be used. Líng Jiăo Gōu Téng Tāng, Zhèn Gān Xī Fēng Tāng, and Tiān Má Gōu Téng Yĭn are representative formulas. The deficient syndrome of internal wind results from yin-blood deficiency generating wind. An example is the spasms and tension in the sinews, or the wriggling of the extremities caused by the internal stirring of deficient wind generated by yin-fluid deficiency in the late stage of warm disease. The therapeutic principle is to nourish yin in order to extinguish

wind. These formulas combine common medicinals that nourish yin and blood such as dì huáng, ē jiāo, bái sháo, jī zĭ huáng, mài dōng, and guī băn. In addition, medicinals that calm the liver and subdue yang are also combined because yin deficiency is usually associated with yang floating. Dà Dìng Fēng Zhū is a common formula used to treat this pattern.

Líng Jiăo Gōu Téng Tāng 羚角钩藤汤Antelope Horn and Uncaria Decoction Source Text Popular Guide to the ‘Treatise on Cold Damage’ (Tōng Sú Shāng Hán Lùn, 通俗伤寒论)

Formula Ingredients

Preparation and Administration Prepare as a decoction for oral use.

Formula Indications Líng Jiăo Gōu Téng Tāng is indicated for a pattern of exuberant heat stirring wind. The symptoms are persistent high fever, irritability, restlessness, twitching and spasms of the extremities, convulsions, coma, a dark red tongue body with a dry tongue coating, or a burnt tongue with prickles, and a wiry, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by warm pathogens entering jueyin causing excessive liver heat generating wind. Excessive heat in liver channel causes refractory high fever and excessive heat that generates wind and flares fire. Moreover, the excessive heat exhausts fluids and the sinews and vessels cannot be properly nourished. Twitching and spasms of the extremities, and even convulsive syncope occur. When the pathogenic heat concentrates fluids into phlegm, the phlegm-heat harasses the heart-spirit and leads to restlessness, irritability, or even coma. A crimson colored dry tongue, or scorched and spotted tongue with a wiry and rapid pulse are indications of excessive liver heat damaging yin. The therapeutic principle is primarily to clear heat, cool the liver, extinguish wind by nourishing yin, supplement fluids and relax the sinews.

Formula Actions Cools the liver and extinguishes wind, and increases fluids to relax the sinews.

Formula Analysis

Continued

Unique Combination Features First off, the major treatment method of cooling the liver and extinguishing wind is combined with supplementing fluid and relaxing sinews in order to treat both the branch and root. The action of cooling the liver and extinguishing wind is accentuated through this combination of methods. Second, clearing and cooling the liver is combined with acrid medicinals that cool, vent, and drain in order to achieve improved efficacy in clearing liver heat.

Formula Applications

1. Essential pattern differentiation Líng Jiăo Gōu Téng Tāng serves as the common formula used to treat excessive liver heat generating wind. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of headache, dizziness and convulsions due to exuberant heat in the liver channel, excessive heat generating wind, or upward reversal of wind yang due to liver heat: epidemic encephalitis B, epilepsy during pregnancy, and hypertension. 4. Cautions and contraindications This formula is not applicable for the late stages of warm disease with the symptoms of relieved fever, exhausted yin-fluids, and internal stirring of deficient wind.

Associated Formulas

Gōu Téng Yĭn (Uncaria Beverage, 钩藤饮) [Source] Golden Mirror of the Medical Tradition (Yī Zōng Jīn Jiàn, 医宗⾦鉴) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and extinguishes wind, boosts qi and relieves convulsions. [Applicable Patterns] Pediatric convulsions due to liver heat generating wind. Symptoms include: high fever, palpitations due to fright, lockjaw, twitching and spasms of the extremities, upward-facing head and eyes. Gōu Téng Yĭn and Líng Jiăo Gōu Téng Tāng are both formulas that clear heat and extinguish wind and they both contain gōu téng and líng yáng jiăo as their chief medicinal. However, Gōu Téng Yĭn is more powerful to extinguish wind and relieve convulsions because it contains quán xiē and tiān má. It also contains rén shēn that can protect the delicate body of a child, so it is applicable for pediatric convulsions characterized by severe convulsions due to liver heat generating wind. Líng Jiăo Gōu Téng Tāng contains shēng dì and bái sháo to supplement fluids and relax the sinews, so it is applicable for excessive heat generating wind with yin damage causing high fever and convulsions.

Case Studies 1. Summerheat-warmth and excessive heat generating wind A 5-year-old boy surnamed Jiang suffered from epidemic encephalitis B in July, 1955 and went to Changsha Infectious Disease Hospital. His symptoms were: coma, high fever, phlegm in the throat, hand and foot cramps, stiffness of the neck and back, both eyeballs turning upward, tightly clenched teeth, blue and purple finger venules, and a rapid, slippery pulse. All these symptoms were indications of wind produced by extreme heat and phlegm clouding the clear orifices. The appropriate treatment was to clear heat and extinguish wind, as well as clear up phlegm and open the orifices. The prescription used was Líng Jiăo Gōu Téng Tāng with modification: shuĭ niú jiăo 15 g, gōu téng 6 g, tiān má 3 g, chuān bèi mŭ 3 g, fú líng 6 g, zhú rú 6 g, jīn yín huā 6 g, lián qiào 3 g, and xī guā cuì yī 30 g. The medicinals were prepared as a decoction with one unit of both Ān Gōng Niú Huáng Săn (Peaceful Palace Bovine Bezoar Pill, 安宫⽜黄散) and Shé Dăn Chén Pí Mò (Snake Gall Citrus Powder, 蛇胆陈⽪末). After taking two doses of the above prescription through a nasal feeding tube, the phlegm-drool was reduced and he began to show improved consciousness. At this point Shé Dăn Chén Pí Mò and Ān Gōng Niú Huáng Săn were removed, dì lóng and sī guā luò were added to the previous formula. After three doses were taken, the fever decreased and the spasms were also relieved. Later, yín huā, lián qiào, tiān má, and shuĭ niú jiăo were removed from the formula and shēng dì, bái sháo, mù guā, and biăn dòu were added. After taking five doses of this formula he was cured and discharged from the hospital.1 Comments: This is a case of pathogenic summerheat invading inward into jueyin. The extreme heat in the liver channel produced wind, which

caused high fever and spasms. Inward invasion of phlegm-heat into the pericardium blocks the orifices and leads to coma, phlegm in throat, and a rapid, slippery pulse. Therefore modifications are made to Líng Jiăo Gōu Téng Tāng to clear heat and extinguish wind, as well as to clear up phlegm and open the orifices. The replacement of líng yáng jiăo by shuĭ niú jiăo and the addition of yín huā and lián qiào is to strengthen the effect of clearing heat, cooling blood, and resolving toxins. The replacement of sāng yè and jú huā by tiān má can improve the strength of calming the liver and extinguishing wind. Xī guā cuì yī (the skin of water melon) is used for clearing summerheat. Phlegm-heat inwardly confounds the heart orifices, therefore, Ān Gōng Niú Huáng Săn and Shé Dăn Chén Pí Mò were added to clear heat, dissolve phlegm, and open the orifices. Turbid phlegm accumulates, and the early use of nourishing and greasy medicinals tends to assist dampness and produce phlegm. Therefore, dì huáng and bái sháo were removed. After taking these medicinals, the closed orifices opened and turbid phlegm reduced. Therefore, Ān Gōng Niú Huáng Săn and Shé Dăn Chén Pí Mò, which dissolve phlegm and open the orifices, were removed and dì lóng and sī guā luò were added to unblock the collaterals and arrest convulsion. When the heat had decreased and wind was extinguished, shuĭ niú jiăo, tiān má, jīn yín huā, and lián qiào were removed. But the yin-fluids were consumed, so shēng dì and bái sháo were added to enrich yin and increase the fluids, and mù guā and biăn dòu were added to remove dampness, fortify the spleen, and harmonize the stomach. The resolution of this case not only firmly complies with its pathomechanism, but also resolves in a sequential manner that makes it a good reference for study. 2. Tetrodotoxism Mr. Li, 41 years old and a staff member of a Beijing hotel came for his initial visit on October 7th, 1992. He ate a globefish by mistake two months

ago and was intoxicated. He had been suffering with trembling, dizziness, numbness of his limbs, disturbed sleep, and high blood pressure for several days before his visit. His tongue was red with a white, greasy coating, and his pulse was rapid and wiry. He was diagnosed with excessive heat in liver channel generating wind. The treatment method was to cool the liver and extinguish wind: líng yáng jiăo (powdered)1.2 g, gōu téng 15 g, sāng yè 10 g, jú huā 10 g, fú shén 15 g, shēng dì 10 g, zhè bèi 10 g, bái sháo 15 g, gān căo 6 g, zhú rú 15 g, dāng guī 20 g, lóng gŭ 20 g, and mŭ lì 20 g. After seven doses were taken, the numbness of his limbs and the trembling were observably relieved, and sleep became easier. The only remaining symptom was a distending sensation in his head and eyes. Therefore, bái sháo was increased to 30g, and xià kū căo 15 g was added to the formula. After seven doses with the modifications were taken, all the symptoms disappeared.2 1 Traditional Chinese Medicine Institute of Hunan Province. Cases of Experienced TCM Doctors in Hunan Province 湖南省⽼中医医案选. Changsha: Hunan Science and Technology Press; 1980. 2 Chen Ming. Selected Cases of Liu Du-zhou’s Clinical Trials 刘渡⾈临证验案精选. Beijing: Academy Press; 1996.

Comments: In this case, eating a globefish caused the intoxication. However, the pulse and symptoms tell that the real pathogenesis was hyperactive yang and exuberant heat in the liver channel, yin-blood depletion, and internal stirring of liver wind. Líng Jiăo Gōu Téng Tāng is not only a formula for warm febrile disease and excessive heat in the liver channel generating wind, but also a solution for hyperactive yang and excessive heat in the liver channel producing wind. So the formula was used to clear heat and calm the liver, as well as to extinguish wind and arrest convulsions. Blood deficiency usually results in numbness, which can be resolved by adding dāng guī to supplement liver blood. Hyperactive yang transformed into wind, so lóng gŭ and mŭ lì were added to calm the liver and subdue yang, as well as to tranquilize the heart and calm the mind. When the

formula took effect, the distending sensation in the head and eyes were blamed on the wind harassing the upper body. In order to drain fire and calm the liver, xià kū căo was added. Additionally, a heavy dosage of bái sháo was adopted to enrich yin and calm and soften the liver.

Zhèn Gān Xī Fēng Tāng 镇肝熄风汤LiverSedating and Wind-Extinguishing Decoction Source Text Records of Chinese Medicine with Reference to Western Medicine (Yī Xué Zhōng Zhōng Cān Xī Lù, 医学衷中参西录)

Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications Zhèn Gān Xī Fēng Tāng is indicated for the pattern of apoplectic stroke. The symptoms are dizziness, vertigo, distension of eyes, tinnitus,

headache with a warm sensation in the head, flushed face, and irritability; there may also be frequent belching, progressive difficulty in moving the extremities, and deviation of the mouth and eyes. In severe cases there is dizziness and falling down, unconsciousness, mental confusion with moments of clarity, and an inability to fully recover after loss of consciousness, and a wiry, long, and forceful pulse.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of wind-like strike caused by liver and kidney yin deficiency, hyperactivity of liver yang, internal stirring of liver wind, and upward reversal of qi and blood. There is vertigo, swollen eyes, and tinnitus because liver yang transforms into wind, which harasses upward when there is liver and kidney yin deficiency and hyperactivity of liver yang. The blood counterflows upwards with the counterflow qi that is ascending due to the wind, so there is a hot and painful sensation in the brain, a drunk-like flush, and possibly a stroke due to the counterflow of qi and blood. A mild case is caused by wind attacking the channels and collaterals, which results in gradual loss of body mobility and a gradual deviation of the mouth. A severe case is caused by wind attacking the zang-fu organs, which results in sudden vertigo, fainting, and unconsciousness. A wiry, long, and powerful pulse is the sign of excessive liver yang. This syndrome has its root in liver and kidney yin deficiency and its branch in the hyperactivity of liver yang and the ascending counterflow of qi and blood. However, the excessive branch overwhelms the deficient root. It should be treated by tranquilizing the liver, extinguishing wind, and subduing blood as the main method and assisted by nourishing the liver and kidney.

Formula Actions

Tranquilizes the liver and extinguishes wind, enriches yin and subdues yang.

Formula Analysis

Unique Combination Features First, this formula conducts the blood flow downward and tranquilizes the liver to subdue yang to treat qi and blood. Second, it tranquilizes and subdues while it nourishes so that the branch and the root are treated simultaneously; although the branch is priority. Third, its ability to tranquilize the liver and subdue yang is achieved by soothing the liver.

Further Clarification Why are medicinals that soothe the liver and regulate qi included in a formula used to treat hyperactivity of liver yang and upward harassing of wind? The liver is the martial organ with an unyielding, ascending, and free nature with an aversion to becoming depressed. If medicinals that direct counterflow downward with heavy sedatives are used in a heavy dosage to force down the liver yang, the ascending and free nature of the liver will be suppressed so that liver qi is constrained and the counterflow of liver qi is further worsened. Therefore medicinals that soothe the liver and rectify qi are used to comply with its free and ascending nature, so that the liver qi is not constrained and the liver yang is easier to subdue and descend.

Formula Applications 1. Essential pattern differentiation Zhèn Gān Xī Fēng Tāng serves as the common formula used to treat wind-like strike whether it is a pre-strike, strike, or post-strike. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of liver-kidney yin deficiency and ascendant hyperactivity of liver yang: hypertension, cerebral thrombosis, cerebral hemorrhage, and angioneurotic headache. 4. Cautions and contraindications It is not applicable for stroke due to qi deficiency and blood stasis.

Associated Formulas Jiàn Líng Tāng (Down Sweeping Decoction, 建瓴汤) [Source] Records of Chinese Medicine with Reference to Western Medicine (Yī Xué Zhōng Zhōng Cān Xī Lù, 医学衷中参西录) [Ingredients]

[Preparation and Administration] Grind the iron rust with water. Decoct the medicinals with the iron water. [Actions] Tranquilizes the liver to extinguish wind, and nourishes yin to calm the mind. [Applicable Patterns] Liver and kidney yin deficiency or liver yang hyperactivity. Symptoms include: vertigo, tinnitus, swollen eyes, amnesia, vexation, insomnia and dreaminess, and a wiry, hard, and long pulse. Jiàn Líng Tāng and Zhèn Gān Xī Fēng Tāng both contain huái niú xī, dài zhĕ shí, lóng gŭ, mŭ lì, and bái sháo, therefore they are both able to tranquilize the liver and extinguish wind, nourish yin to subdue yang and are used to treat ascending hyperactive liver yang due to liver and kidney yin deficiency. However Jiàn Líng Tāng contains shēng dì, huái shān yào, and băi zĭ rén, so it is better to calm the heart and tranquilize the mind. Therefore it is used to treat ascending hyperactive liver yang resulting in insomnia with profuse dreaming and restlessness of the heart spirit. Zhèn Gān Xī Fēng Tāng is more powerful to tranquilize and subdue, so it is applicable for ascending hyperactivity of the liver yang and counterflow of qi and blood, which results in a hot and painful sensation in the brain, drunk-like flush, or even wind-stroke coma.

Case Studies

1. Dizziness After Mr. Liu arrived in Tianjin, he often had a fever, and occasionally he felt dizzy and had an uncomfortable sensation in his heart. His pulses were wiry, long, and vigorous on both sides. All of these signs were indications that blood was congested in the brain. These symptoms were due to congestion in the brain caused by prolonged indignation and anxiety. Lǜ dòu was wrapped in bags and put into his pillow to serve as an external treatment to cool the heat in his head. After taking several doses of Zhèn Gān Xī Fēng Tāng with dì huáng 1 liang added, the heat in the head disappeared. At that point, chuān liàn zĭ was removed and the dosage of shēng dì huáng was changed to six qian. The medicinals were stopped once the pulse calmed and his anxiety was relieved after ten days.1 Comments: The patient in this case was often anxious and angered easily, which led to the consumption of liver and kidney yin-blood. The dizziness and heat sensation in his head was caused by yin not matching with yang, water failing to nourish wood, ascending hyperactive liver yang, and wind harassing the upper body. Therefore, Zhèn Gān Xī Fēng Tāng was adopted to tranquilize the liver and extinguish wind, enrich yin and subdue yang. Shēng dì huáng was added to enrich yin, clear heat, and cool the liver and lǜ dòu was put in his pillow to clear heat and lower qi. Internal and external treatments were combined in this case. Once the condition was relieved, chuān liàn zĭ was removed because its bitter and dry properties will damage yin. The dosage of shēng dì huáng was also reduced to prevent its cold nature from producing dampness and hampering the stomach. Finally, the disease was cured. 2. Wind-strike 1 Zhang Xi-chun. Records of Chinese Medicine with Reference to Western Medicine 医学衷中参 西录. Shijiazhuang: Hebei People’s Publishing House; 1957.

Once in Cangzhou I treated a 64-year-old patient. Ten days prior he got annoyed and developed a headache, but he paid no attention to it. Then one day while standing up, he suddenly fell down and appeared as though he was in coma. When he was moved, he revived but his left hand and foot could not move and he felt an extreme headache. The doctor adopted medicinals that clear fire and unblock the collaterals along with several qian of shēng huáng qí, imitating the way Wang Xun-chen used it in Bŭ Yáng Huán Wŭ Tāng. But the headache became more severe with an unbearable stabbing pain. When I examined him his pulses were wiry, long on the left hand and surging, long on the right and both were excessive when pressed hard. When he was asked about the sensation in his heart, he said that he felt a constant heat. His family told me that he was an alcoholic and he had been especially annoyed for several days recently, so he drowned his sorrows even when he was hungry. Due to the surging pulse on the right hand, one liang of shēng shí gāo was added to the formula: huái niú xī 1 liang, shēng bái sháo 6 qian, shēng lóng gŭ 6 qian, shēng mŭ lì 6 qian, shēng dài zhĕ shí 6 qian, xuán shēn 4 qian, chuān liàn zĭ 4 qian, lóng dăn căo 3 qian, and gān căo 2 qian. After two doses, the headache disappeared and the pulse became calm and his left hand and foot could move once again. So the prescription was modified: dāng guī 5 qian, zhĕ shí 5 qian, shēng bái sháo 5 qian, xuán shēn 5 qian, tiān dōng 5 qian, shēng huáng qí 3 qian, rŭ xiāng 3 qian, mò yào 3 qian, and hóng huā 1 qian. Several doses later, he could walk with the help of cane. 1 Comments: The patient first got a headache, and then fell into coma ten days later. He was awakened with hemiplegia and a wiry, long pulse on the left, and a surging, long pulse on the right. These were the symptoms of stroke. His condition was triggered by liver-kidney yin deficiency and his habitual intake of alcohol while in a bad emotion. The liver yang

transformed into fire and wind, the stomach fire grew intense within yangming, and ascending wind rising with stomach fire resulted in an upward reversal of qi and blood. Using a formula that clears fire and unblocks the collaterals didn’t match the disease pattern. The condition became more severe when huáng qí was added by mistake to boost qi and raise yang. The therapeutic method suitable for treating his condition was to clear liver heat and drain fire and subdue yang and extinguish wind, as well as, lead qi and blood downward. Therefore, Zhèn Gān Xī Fēng Tāng was used with lóng dăn căo to clear the liver and drain fire and shēng shí gāo to clear the stomach and subdue fire. The patient’s hand and foot finally recovered after taking the formula used to enrich yin and subdue yang and boost qi to unblock the collaterals.

Tiān Má Gōu Téng Yĭn 天麻钩藤饮Gastrodia and Uncaria Decoction Source Text Newly Explained Diagnosis and Treatment of TCM Internal Medicine and Miscellaneous Diseases (Zhōng Yī Neì Kē Zá Bìng Zhèng Zhì Xīn Yì, 中 医内科杂病证治新义)

Ingredients

1 Zhang Xi-chun. Records of Chinese Medicine with Reference to Western Medicine 医学衷中参 西录. Shijiazhuang: Hebei People’s Publishing House; 1957.

Preparation and Administration Prepare as a decoction.

Formula Indications Tiān Má Gōu Téng Yĭn is indicated for patterns of hyperactive liver yang and ascending liver wind. The symptoms are headache, dizziness and vertigo, insomnia with profuse dreaming; or a bitter taste in the mouth, flushed face, a red tongue with a yellow tongue coating, and a wiry or rapid pulse.

Analysis of Fundamental Pattern Pathogenesis Liver and kidney deficiency with hyperactive liver yang generating wind and heat is the cause of this pattern. Hyperactive liver yang leads to ascending wind that harasses the upper body and causes headache and vertigo. Excessive liver yang generates heat that harasses the heart resulting in irritability, insomnia, and excessive dreaming. A red tongue body with a yellow coating and a wiry, rapid pulse are the signs of hyperactive yang generating heat. The root of this syndrome is deficiency and the branch is excess, although the branch is more pronounced. Therefore, the treatment emphasizes calming the liver to extinguish wind, while clearing wind to calm the mind and nourishing liver and kidney to assist.

Formula Actions Calms the liver and extinguishes wind, clears heat and invigorates blood, supplements and boosts the liver and kidney.

Formula Analysis

Continued

Unique Combination Features Calming the liver and extinguishing wind, the main therapeutic method, is combined with clearing heat, invigorating blood, calming the mind, and nourishing the liver and kidney to treat both the root and the branch. In this pattern the branch is taken as the priority.

Formula Applications 1. Essential pattern differentiation Tiān Má Gōu Téng Yĭn serves as the common formula used to treat hyperactive liver yang and liver wind harassing the upper body. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of ascending hyperactive liver yang or liver wind harassing the upper body: hypertension, cerebrovascular accident, and auditory vertigo.

Comparison & Contrast Zhèn Gān Xī Fēng Tāng vs. Tiān Má Gōu Téng Yĭn

Continued

Case Studies Wind-strike Mr. Dong, a 64-year-old doctor, came to the hospital with his medical record (no. 7388) on April 4th, 1990. His chief complaints were dizziness, weakness in the left body, unclear speech, and choking when drinking water for three days. When I examined him, he had a clear mind, sluggish speech, muscle strength class III of both upper and lower limbs on the left, blood pressure 190/110 mm Hg, a red tongue with a thin yellow tongue coating, and a wiry pulse. CT report: Lacunar infarction 0.4 cm long in the brainstem. It was diagnosed as multiple lacunar infarctions. Pattern differentiation: This case of stroke was wind striking the channels and collaterals, which belongs to ascending hyperactive liver fire. The treatment is to clear fire, calm the liver, and extinguish wind.

Prescription: Tiān má 10 g, gōu téng 15 g, shēng shí jué míng 30 g, zhī zĭ 10 g, huáng qín 10 g, chuān niú xī 12 g, dì lóng 12 g, sāng jì shēng 10 g, yì mŭ căo 20 g, and jī xuè téng 15 g. One dose per day, prepared as a decoction. After ten days the dizziness stopped, and three days later the left upper and lower limbs regained muscle strength class V and the patient no longer choked when drinking water. Since he had occasional dry stools and is thirsty, huā fĕn 10 g and huŏ má rén 15 g were added in the original formula. After five doses, he left hospital with all of the symptoms gone. One year later, the patient lived and worked normally without any sequelae. 1 1 Luo He-gu. Internal Medicine Cases 内科医案. Beijing: China Medical Science and Technology Publishing; 2005.

Comments: Aging, stroke, dizziness, a red tongue with a yellow coating, and a wiry pulse are all signs of liver and kidney deficiency and hyperactive liver yang generating heat and wind which harass the upper clear orifices and scurry along the channels and collaterals. Tiān Má Gōu Téng Yĭn is effective for clearing fire, calming the liver and extinguishing wind, and invigorating blood. Therefore, it is modified with dì lóng and jī xuè téng to unblock the collaterals. Dù zhòng was removed so the effect in draining fire, calming the liver, and extinguishing wind was more obvious. Neither fú shén nor yè jiāo téng was used because the patient was not upset and didn’t suffer insomnia. Thirst and dry stool resulted from deficiency of the stomach and intestinal fluids. This formula has no effect to enrich yin, so huā fĕn and huŏ má rén were added to promote fluid production in order to quench thirst and moisten the intestines to promote defecation.

Dà Dìng Fēng Zhū ⼤定风珠Major WindStabilizing Pill Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Prepare the ingredients, except ē jiāo and jī zĭ huáng, as a decoction for oral use. Add ē jiāo by melting it into the decoction, and blend jī zĭ huáng into the strained decoction while stirring equably.

Formula Indications

Dà Dìng Fēng Zhū is indicated for a pattern of stirring of wind due to yin deficiency. The symptoms are clonic convulsions of the extremities, weak physique, lassitude of the spirit, a deep red tongue body with a scanty tongue coating, and a weak pulse; patients have a strong tendency of desertion.

Analysis of Fundamental Pattern Pathogenesis This is a pattern caused by the prolonged retention of pathogenic heat damaging the genuine yin in the late stage of warm disease; if sweating had been induced incorrectly or if purged incorrectly, yin-fluids would be damaged, which leads to wind stirring. When the liver and kidney yin-fluids are exhausted, water fails to nourish wood, which stirs up deficient wind; convulsive limbs may also result. Exhausting genuine yin results in yang having no place to adhere to. Therefore there is emaciation and lassitude, a crimson tongue with a scanty coating, a weak pulse, and the tendency of desertion. The fundamental feature of this pattern is that the pathogenic heat is nearly eliminated, but there is only a little genuine yin left and is on the edge of desertion. The therapeutic principles used to remedy this pattern are to nourish yin-fluids to supplement the exhausting genuine yin and calm and extinguish the internal stirring of deficient wind.

Formula Actions Enriches yin and extinguishes wind.

Formula Analysis

Special Combination Features In this formula, treating the root refers to moistening and nourishing yin-fluids with sweet and moistening medicinals, while treating the branch refers to subduing yang and astringing. While both the root and the branch are addressed, the priority is put on treating the root. The formula extinguishes wind by nourishing and preventing genuine yang from deserting.

Further Clarification The reason why medicinals that subdue yang are used in this formula is because yin and yang are rooted in each other. When the genuine yin has become exhausted, yang loses its root; when yin is gone, yang has no place to root and floats to the exterior. When genuine yang floats, not only does it generate wind, but it is also in danger of desertion. Calming medicinals are able to subdue the genuine yang; therefore they are used to help extinguishing wind and preventing genuine yang from deserting.

This formula is a modification of Jiā Jiăn Fù Mài Tāng (consisting of zhì gān căo, gān dì huáng, shēng bái sháo, ē jiāo, mài dōng, and má rén). Pathogenic heat from the prolonged warm disease damages genuine yin, which results in deficient fire stirring internally. Therefore many medicinals that nourish yin to subdue yang, such as jī zĭ huáng, wŭ wèi zĭ, guī băn, biē jiă, and mŭ lì are added and then Jiā Jiăn Fù Mài Tāng, a formula that nourishes yin and moistens dryness, is converted to a formula that nourishes yin and extinguishes wind.

Formula Applications 1. Essential pattern differentiation Dà Dìng Fēng Zhū serves as the most common formula used for severe damage of kidney yin with internal stirring of deficient wind in the late stage of warm disease. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of stirring of wind due

to yin deficiency such as Japanese B encephalitis sequelae, stroke sequelae, hyperthyroidism and neuropathic vibrations. 4. Cautions and contraindications This formula is not applicable to patients with deficient yin-fluids and excessive pathogenic heat.

Associated Formulas Sān Jiă Fù Mài Tāng (Three Shells Pulse-Restoring Decoction, 三甲 复脉汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Nourishes yin to extinguish wind. [Applicable Patterns] Prolonged retention of pathogenic heat in the lower jiao and deep heat with severe reversal cold in a warm disease. Symptoms include: notable

palpitations or even angina, wriggling of the extremities, a crimson colored tongue body with a scanty coating, and a wiry, racing pulse. Ē Jiāo Jī Zĭ Huáng Tāng (Donkey-Hide Gelatin and Egg Yolk Decoction, 阿胶鸡⼦黄汤) [Source] Popular Guide to the ‘Treatise on Cold Damage’ (Tōng Sú Shāng Hán Lùn, 通俗伤寒论) [Ingredients]

[Preparation and Administration] The jī zĭ huáng is decocted first and then used in place of water to decoct other medicinals. [Actions] Enriches yin and nourishes blood, softens the liver and extinguishes wind. [Applicable Patterns] Prolonged retention of pathogenic heat, insufficient yin-blood, and deficient wind stirring internally. Symptoms include: spasms of the sinews, convulsions of the extremities, vexation and insomnia, vertigo, a crimson colored tongue body with scanty coating, and a wiry, rapid pulse.

Dà Dìng Fēng Zhū, Sān Jiă Fù Mài Tāng, and Ē Jiāo Jī Zĭ Huáng Tāng are formulas that nourish yin and extinguish wind. They are applicable to warm disease damaging yin with internal stirring of deficient wind. However, their actions and indications differ in degree. Dà Dìng Fēng Zhū which consists of Sān Jiă Fù Mài Tāng with added jī zĭ huáng and wŭ wèi zĭ, is the strongest formula in terms of nourishing yin and extinguishing wind. It also has the action of astringing; therefore, it is applicable to severe damage of genuine yin resulting in a weak pulse and the tendency of yang desertion. Sān Jiă Fù Mài Tāng is weaker to nourish yin and extinguish wind, but stronger to nourish the heart and restore the pulse. Therefore it is applicable to patients with internal stirring of deficient wind, who have a thready and racing pulse as well as severe palpitations. Containing gōu téng and fú shén, Ē Jiāo Jī Zĭ Huáng Tāng is the strongest to cool the liver and calm the mind. Therefore, it is applicable to wind stirring due to yin deficiency with existing liver heat, which results in a thready and rapid pulse and restlessness.

Case Studies 1. Headache due to deficient wind It was sometime between 9 pm to 11 pm on Chinese New Year’s Eve when 22-year-old Mrs. E caught a cold and suffered from obstructive pain. She recently gave birth to a baby, which left her vulnerable to external invasion. The doctor gave her extremely dry medicinals such as guì zhī and fù zĭ to treat the cold and obstructive pain. The effect was so outstanding that he thought it was indispensable for the patient and used it for more than one year to treat her. The doctor did not realize that warm dryness was different from warm nourishment; the former can treat diseases but by no means can preserve health. Overusing this method led to the exhaustion of shaoyang fluids. So the patient developed a jueyin headache with an unbearable ache

centered at her apex. She also developed photophobia, which caused her to scream as soon as she saw any small ray of light, even as small as a bean, through the window. The pain only dissipated once the room was pitch-black again. She suffered syncope four to five times a day, and her wiry pulse was thready, without strength when pressed. This was an emergency, so Dà Dìng Fēng Zhū was used to subdue yang and cultivate yin in order to extinguish liver wind. Prescription: Dà shēng dì 8 qian, má rén 4 qian, shēng bái sháo 4 qian, shēng guī băn 6 qian, mài dōng 4 qian, shēng ē jiāo 4 qian, shēng biē jiă 6 qian, hăi shēn 2 pieces, shēng mŭ lì 6 qian, jī zĭ huáng 2 yolks, and zhì gān căo 5 qian. The above medicinals were decocted to eight cups before the dregs were disposed and then further decocted to four cups. The decoction was taken in small doses at short intervals. On the first day of Chinese New Year, a slight effect was achieved and then one liang of bào yú piàn (abalone) was added to the formula. The medicinals were decocted down to 10 cups, the dregs were disposed of, and then it was further decocted down to five cups. The decoction was taken as before. More effect was achieved on the second day of Chinese New Year. The therapeutic method was the same as the previous one. On the third day, the syncope stopped and the headache was relieved, but she was still afraid of light. The treating method remained the same. On the fourth day, her upper lumbar was hot, while the lower was cold; the left side of her body was sweating, while the right side was not. I had never come across this type of syndrome in the old classics. However, an old saying arose in my mind: “When stringed instruments are not in harmony, the strings need to be replaced and tuned.” The syndrome had to be cured once the syncope recovered. On the basis of the previous formula, Dà Dìng Fēng Zhū was reduced to the half of the weight of the original prescriptions, and qīng hāo 8

fen was added in the formula. After taking it, syncope appeared two to three times during the night. On the fifth day, Dà Dìng Fēng Zhū was then returned to the original dosage in the prescription. After taking one dose the syncope stopped and the mind calmed. On the seventh day, the prescription remained the same. On the eighth day, the prescription continued to remain the same as before and the photophobia of the patient gradually relieved. Since the twentieth day of the first lunar month, the veiling was removed. After taking the decoction with one Zhuān Xī Dà Shēng Gāo (Special Vigorous Great Engendering Extract, 专翕⼤⽣膏) until the Spring Equinox, the patient recovered totally.1 Comments: The patient in this case took extremely hot and dry medicinals for a long time, and the outcome of which was not different from an enduring warm febrile pathogen. The dryness and heat damaged the genuine yin, which resulted in yin deficiency failing to control yang, and water depletion failing to nourish wood. This caused deficient wind to harass upward, pain in the apex, occasional fainting, and a wiry, thready, rapid, and powerless pulse. Her preference to be in the dark and the photophobia was a symptom of yin deficiency’s hatred of seeing the sunlight. Therefore, Dà Dìng Fēng Zhū with wŭ wèi zĭ removed, and hăi shēn and bào yú piàn added were used to enrich yin and nourish fluid in order to extinguish deficient wind. After taking the medicinals, the deficient wind was relieved to some degree, but yin had not yet recovered. Therefore, the syncope stopped and the ache was relieved, but the photophobia still existed. In addition, her upper body was hot, while the lower was cold; and half of her body was sweating, while the other side not. Yin deficiency and floating yang, as well as the disharmony of yin and yang lead to this imbalance. So, the method of enriching yin and extinguishing wind was still taken, but the dosage was reduced. In addition, bittercold and aromatic qīng hāo was added to clear

deficiency-heat and treat the syncope. Based on this, the former prescription was used to enrich yin and nourish fluid so as to extinguish deficient wind. Zhuān Xī Dà Shēng Gāo was used to enrich and nourish the liver and kidney, and the patient finally recovered. The patient in this case took the medicinals for more than two months. She followed a method of taking small doses in short intervals. The purpose of this method was to gradually engender yin-blood because yin-blood cannot generate in a short time. 2. Hyperthyroidism In 1971, a 47-year-old lady had palpitations, spontaneous sweating, irritability, and an increased appetite. She had taken many medicines but did not have satisfactory response. The signs and symptoms were palpitations, insomnia, aversion to heat, sweating, dizziness, soreness and weakness of the waist and knees, trembling fingers, enlarged goiter, a red tongue body with a scanty coating, and a thready and rapid pulse. This was caused by liver-kidney yin deficiency along with the binding of phlegm and qi. Therefore, má rén was removed from Dà Dìng Fēng Zhū to enrich and supplement essence and marrow of the liver and kidney, subdue yang to extinguish wind. Xuán shēn and bèi mŭ were added to dissolve phlegm, soften hardness, and dissipate masses. 1 Wu Ju-tong. Wu Ju-tong Medical Records 吴鞠通医案.Beijing: People’s Medical Publishing House; 1960.

Prescription: Guī jiă 30 g, biē jiă 30 g, shēng mŭ lì 30 g, shēng dì 20 g, shú dì 20 g, bái sháo 18 g, gān căo 10 g, mài dōng 10 g, ē jiāo 10 g, xuán shēn 10 g, bèi mŭ 10 g, wŭ wèi zĭ 10 g, and jī zĭ huáng 2 pieces (infused). After taking sixteen doses, she felt her symptoms were alleviated. She continued to take another thirty doses and all the symptoms were eliminated. Her condition did not reoccur as noted in followup visits.1

Comments: The patient in this case was diagnosed with hyperthyroidism according to Western medicine. The signs and symptoms were palpitations, insomnia, fear of heat, sweating, dizziness, blurry vision, soreness and weakness of the waist and knees, trembling fingers, a red tongue body with scanty coating, and a thready, rapid pulse. These were the symptoms of liver-kidney yin deficiency, yin failing to nourish yang, and deficient wind stirring internally. The enlarged goiter was caused by deficient fire burning the fluids to cause phlegm, and then phlegm and qi bind together to form “goiter”. Therefore, má rén was removed from Dà Dìng Fēng Zhū to enrich and supplement liver and kidney yin, and subdue yang so as to extinguish deficient wind. In addition, biē jiă and mŭ lì were used to soften hardness and dissipate masses. Xuán shēn and bèi mŭ were used to enrich yin and clear heat, dissolve phlegm, and dissipate masses. Thus, this formula treats the root and branch simultaneously.

Summary There are ten formal formulas and seven associated formulas within the wind-expelling formulas chapter. They are categorized as either:

● wind-expelling formulas that scatter and dissipate external wind ● wind-expelling formulas that calm and extinguish internal wind 1. Wind-expelling formulas that scatter and dissipate external wind Chuān Xiōng Chá Tiáo Săn contains acrid and dispersing medicinals as key components, and it is effective for scattering and dissipating wind pathogens to relieve headaches. It is used to treat external wind pathogens that invade upward to the head and result in a headache. Dà Qín Jiāo Tāng is mainly used to scatter and dissipate wind pathogens and it can also nourish and invigorate blood and clear heat. Taking care of both the pathogenic and

healthy aspects, it treats both the root and branch. It is used in the initial stage of pathogenic wind attacking the channels and collaterals where the sinews fail to be nourished because of deficient blood. The signs and symptoms include facial palsy, loss of speech due to a stiff tongue and dysfunction of the four limbs. Xiăo Huó Luò Dān is used to dispel wind, eliminate dampness, dissolve phlegm to unblock the collaterals, invigorate blood, and relieve pain. It is mainly used for prolonged bì syndrome due to cold-dampness, phlegm, and blood stasis blocking and obstructing the channels and collaterals. Both Qiān Zhèng Săn and Yù Zhēn Săn can dispel wind, dissolve phlegm, and arrest convulsion. But the former is effective for symptoms of facial palsy caused by wind-phlegm blocking the channels and collaterals in the head and face. While the later can dispel wind, dissolve phlegm, and relieve and suppress convulsions. It is commonly used to treat tetanus. Xiāo Fēng Săn is commonly used to treat rubella and eczema because it can scatter wind, dispel dampness, clear heat, and generate blood. 2. Wind-expelling formulas that calm and extinguish internal wind 1 Xiao Li-wei. Dà Dìng Fēng Zhū Treating Miscellaneous Diseases ⼤定风珠治杂病. Zhejiang Journal of Traditional Chinese Medicine. 1987; (3): 139.

Líng Jiăo Gōu Téng Tāng, Zhèn Gān Xī Fēnɡ Tāng, and Tiān Má Gōu Téng Yĭn are all formulas that calm the liver and extinguish wind. Líng Jiăo Gōu Téng Tāng is effective for clearing heat, cooling the liver, and extinguishing wind. It is used for excessive heat in the liver channel, and extreme heat generating wind. Zhèn Gān Xī Fēnɡ Tāng calms the liver, subdues yang, extinguishes wind, and leads blood downward. It is

commonly used to treat liverkidney yin deficiency, ascending hyperactive liver yang, wind harassing upward with rising counterflow of qi and blood. The result is a headache, dizziness, eye distention, tinnitus, red face, and wind strike. Tiān Má Gōu Téng Yĭn, with the function to clear heat,

invigorate blood, and calm the mind, is usually used to treat hyperactive liver yang and liver wind harassing upward, which results in headache, dizziness, and insomnia. Dà Dìng Fēng Zhū, which can enrich yin and extinguish wind, is applicable in the late stage of warm disease to treat convulsions in limbs due to heat scorching kidney yin resulting from deficient wind stirring internally.

Questions 1.What are the therapeutic methods utilized in Zhèn Gān Xī Fēng Tāng for the treatment of wind-like strike, and why they are used? 2.Why are the formulas that scatter and dissipate external wind not to be used for internal wind patterns? Why are the formulas that calm and extinguish internal wind not to be used in external wind patterns? 3.What is the meaning of “extinguishing wind is achieved by treating blood because normal blood circulation facilitates the disappearance of wind”? 4.What are the differences in formula indications and medicinal combinations between Líng Jiăo Gōu Téng Tāng and Dà Dìng Fēng Zhū? Explain the differences.

Endnotes: [1] 治风先治⾎，⾎⾏风⾃灭 [2] 治之以峻，⾏之以缓 [3] 诸风掉眩，皆属于肝

CHAPTER 13 Dryness-Relieving Formulas Dryness-relieving formulas are used to treat dryness patterns. Their major ingredients are light, acrid, dispersing medicinals that relieve external dryness with light diffusion and sweet, cooling, moistening medicinals that enrich yin and moisten dryness. Dryness patterns are classified as external and internal types. An external dryness pattern is caused by the invasion of external dryness pathogenic factors which most often occurs during the autumn. The climate of the autumn season can be either cold or hot. Therefore, external dryness patterns can be further categorized as either cool-dryness or warm-dryness depending on the climatic conditions. Internal dryness is the result of body fluid depletion in the zang-fu organs. According to the depth and the organs affected, internal dryness patterns are further classified as patterns that affect the upper, middle, or lower jiao. The lung, stomach, kidney and large intestine are the most commonly involved zang-fu organs. Generally speaking, upper jiao dryness most often affects the lung, middle jiao dryness most often affects stomach, and lower jiao dryness most often affects the kidney. Patterns of external dryness are relieved by light diffusion while patterns of internal dryness are treated by nourishing and moistening. Therefore, the formulas in this chapter are divided into those that relieve external dryness by light diffusion and those that enrich yin and moistening dryness.

It is important to properly differentiate between external dryness and internal dryness when treating dryness patterns. In external dryness patterns, one must further differentiate between cool-dryness and warm-dryness. The body has complex relationships among the various zangfu organs, body regions, and between the exterior and interior. Therefore, external dryness is commonly accompanied by internal dryness. Upper dryness and lower dryness will frequently appear simultaneously and the treatment should therefore be adjusted according to the unique clinical presentation. For example, an externally-contracted warm-dryness pattern may not only manifest with a fever and headache, but it may manifest instead as an upper dryness pattern with a dry throat and mouth and a cough with scanty sputum. When treating this kind of pattern the method of relieving dryness-heat by light diffusion should be used together with cooling and moistening the lung. An upper dryness pattern that manifests with a dry throat and mouth and a cough with scanty or bloody sputum is often caused by kidney yin deficiency with deficient fire flaming upward. The appropriate treatment is to nourish yin, moisten the lung, and regulate the metal and water elements. This example illustrates the importance of selecting therapeutic methods according to the unique condition. Pathogenic dryness easily transforms into heat that damages fluids and consumes qi. Therefore it is often necessary to add heat-clearing, firedraining, qi-boosting, and fluid-promoting medicinals when using drynessrelieving formulas. Often, it is suitable to use sweet-cold or salty-cold medicinals. Dryness patterns should not be treated with acrid, aromatic medicinals that consume qi nor bitter-cold medicinals. Additionally, sweetcold medicinals that nourish and moisten tend to encourage the development of dampness and obstruct the qi dynamic. Therefore, they should not be used

in those with a damp constitution or in cases with diarrhea due to spleen deficiency.

Section 1 Formulas that Relieve External Dryness by Light Diffusion Formulas that relieve external dryness by light diffusion are applicable to both externallycontracted cool-dryness patterns and warm-dryness patterns. Cool-dryness manifests from the cold, dry pathogenic factors of the late autumn as the environment becomes increasingly cold and dry. As cooldryness dominates the environment during that season, they may affect the lung’s function to diffuse qi. The signs and symptoms include headache, aversion to cold, coughing with thin sputum, stuffy nose, dry throat, and a thin white tongue coating. As patterns of cool-dryness share many symptoms with the more severe exterior wind-cold pattern of winter, it has traditionally been referred to as “lesser cold” or “smaller cold”. The therapeutic focus of all the formulas in this category is to warm and moisten cool-dryness and to gently disperse. Thereby, formulas that treat cool-dryness often use bitter, acrid, warming, and moistening medicinals like zĭ sū yè and xìng rén. A good example is the formula Xìng Sū Săn. It treats a condition caused by dry-heat or long periods of sunshine without rain in the early autumn. In this circumstance, the warm-dryness is caused by dry-heat pathogenic factors attacking the lung and lung qi failing to purify. The signs and symptoms include a feverish sensation in the body, headache, dry coughing with scanty sputum, labored breathing, dry nose, thirst, a red tongue at the tip and margins with a thin, white or yellow coating. Formulas that treat warmdryness patterns often use acrid, cool, sweet, and moistening medicinals

such as sāng yè, dòu chĭ, xìng rén, and shā shēn. Two common formulas are Sāng Xìng Tāng and Qīng Zào Jiù Fèi Tāng.

Xìng Sū Săn 杏苏散Apricot Kernel and Perilla Powder Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Prepare as a decoction to be ingested while warm.

Formula Indications Xìng Sū Săn is indicated for patterns of externally-contracted cooldryness. The symptoms are aversion to cold, mild headache, coughing with scanty sputum, stuffy nose, and a dry throat. The tongue coating is white, and the pulse is wiry.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by cool-dryness attacking the exterior with failure of the lung qi to diffuse and internal obstruction of phlegm-dampness. The mild headache and chills without sweating indicate that cool-dryness has attacked the skin and hair. Headaches caused by cool-dryness are less severe than headaches due to cold damage syndrome. Cool-dryness may invade the lung and cause failure of the lung to diffuse and govern descent as well as failure of lung qi to distribute fluids. As a result, water accumulates and turns into phlegm causing symptoms such as coughing with thin sputum. Cool-dryness damages the lung to cause dysfunction of lung qi characterized by a stuffy nose and a dry throat. A white tongue coating and a wiry pulse prove the pattern of cool-dryness with sputum-dampness. The composition of this formula is based on the principle described within Basic Questions: “Dry pathogenic qi is treated internally with bitter and warm medicinals, and sweet and acrid medicinals are used adjunctively”[1]. This disorder should be treated primarily via relieving cool-dryness by light diffusion and supported by regulating the function of the lung to dissolve phlegm.

Formula Actions Relieves cool-dryness by light diffusion, regulates lung function, and dissolves phlegm.

Formula Analysis

Formula Applications 1. Essential pattern differentiation Xìng Sū Săn is a characteristic formula commonly used to relieve cooldryness by light diffusion, and a popular formula used to treat cough due to wind-cold. This clinical pattern is marked by:

2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of externally-contracted cool-dryness or a mild pattern of externally-contracted windcold, failure of lung qi to diffuse, and internal obstruction of phlegm-dampness: upper respiratory tract infection, chronic bronchitis and emphysema. 4. Cautions and contraindications This formula is not applicable for patients diagnosed with the cooldryness that has transformed into warm-dryness or wind-heat.

Case Studies Headache

13-year-old Zhao came for an initial visit on November 29th for a headache. His pulse was floating and wiry but not tight, and there was no sweating detected. Xìng Sū Săn was prescribed: xìng rén 2 qian, qiāng huó 4 qian, shēng jiāng 3 slices, sū yè 3 qian, gān căo 1.5 qian, dà zăo 2 pieces, fáng fēng 2 qian, jié gĕng 3 qian. The patient was advised to decoct the medicinals down to two cups and then drink one cup first and cover with a quilt to produce a slight sweat (as opposed to a great dripping sweating). If he sweats after taking the first cup, then there is no need to take the second cup. However, if he doesn’t sweat at that point, take the second cup in addition. If he still does not sweat, continue taking this decoction until he does. After there is a sweat, the patients needs to rest in a place without wind, eat porridge, and avoid greasy food.1 Comments: This case happened in late autumn and was diagnosed as external contraction of cool-dryness. Therefore, Xìng Sū Săn is the preferred formula. The pulse being floating but not tight and the obvious headache indicate the cold qi was strong. Therefore, qiāng huó and fáng fēng were added to increase the strength of the formula to dissipate the pathogen. Since the patient had no cough and only a little phlegm, the medicinals that rectify the lung and dissolve phlegm such as bàn xià, chén pí, fú líng, and qián hú were removed. Wu’s method of reducing and combining medicinals is a good study for those who want to learn more.

Sāng Xìng Tāng 桑杏汤Mulberry Leaf and Apricot Kernel Decoction Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) 1 Wu Ju-tong. Wu Ju-tong’s Medical Records吴鞠通医案. Beijing: People’s Medical Publishing House; 1960.

Formula Ingredients

Preparation and Administration Decoct the ingredients with 2 cups of water until it is reduced to 1 cup. Take the strained decoction once a day. If the condition is severe continue to take 1 cup each day. (Modern use: prepare the ingredients as a decoction).

Formula Indications

Sāng Xìng Tāng is indicated for the pattern of externally-contracted warm-dryness. The symptoms are mild fever, thirst, dry throat and nasal cavities, dry cough without sputum, or with scanty, and sticky sputum. The tongue body is red with a thin, white and dry coating. The pulse is floating and rapid and is large on the right side.

Analysis of Fundamental Pattern Pathogenesis Sāng Xìng Tāng is designed to treat mild patterns of externallycontracted warm-dryness injuring the lung fluids. Since warm-dryness invades the lung-wei in autumn, the resulting condition is mild and occurs at the exterior level to induce a mild fever. Dryness also depletes the lung fluids causing failure of the lung qi to purify leading to symptoms such as thirst, dry throat and nasal cavities, dry cough without sputum, or with scanty, and sticky sputum. This pattern resembles exterior wind-heat, yet this pattern is caused by warm-dryness. The lung fluids have been depleted and therefore the therapeutic principle is to clear and diffuse dryness-heat at the exterior, moisten the lung and dissolve phlegm in the interior.

Formula Actions Clears and diffuses warm-dryness, moistens the lung and dissolves phlegm.

Formula Analys

Continued

Formula Applications 1. Essential pattern differentiation Sāng Xìng Tāng is a formula commonly used to treat mild patterns of warm-dryness that have damaged the lung. This clinical pattern is marked by:

● mild fever ● dry cough without sputum, or with scanty and sticky sputum ● rapid and large pulse on the right 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of externally-contracted warmdryness invading lung-wei: upper respiratory tract infection, acute and chronic bronchitis, haemoptysis and pertussis. 4. Cautions and contraindications The medicinals in this formula should be used in small dosages and should only be cooked for a short period of time because the pathogens are not severe and are located in the superficial layer. It was explained in a postscript from the formula’s source text: “Light medicinals should not be used in large dosage or decocted for a long time because if they are, light medicinals cannot act at the qi level but will act on the other levels”[2].

Comparison & Contrast Xìng Sū Săn vs. Sāng Xìng Tāng

Sāng Jú Yĭn vs. Sāng Xìng Tāng

Associated Formulas Qiào Hé Tāng (Forsythia and Mint Decoction, 翘荷汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Relieves dryness-heat by light diffusion.

[Applicable Patterns] Warm-dryness invades qi level. Symptoms include: tinnitus, red eyes, swollen gum, and sore throat.

Case Studies Fever Miss Xu in Shengling, Shaoxing city, Zhejiang Province had a fever due to autumn dryness. The symptoms included: a floating pulse, cough and urgent qi, a slightly yellow tongue coating, and thirst without much desire to drink. The symptoms were not slight, and attention should be paid to prevent it from getting aggravated. The prescription included bò he 1.5 qian, sāng yè 3 qian, xìng rén 3 qian, zhè bèi mŭ 3 qian, lián qiào 3 qian, chán yī 1.5 qian, jú hóng 1 qian, dàn dòu chĭ 3 qian, tiān huā fĕn 3 qian, qián hú 1.5 qian, dàn zhú yè 3 qian and lú gēn 1 liang. It was prescribed for two doses. Comments: This is a case of warm-dryness damaging the lung. Modified Sāng Xìng Tāng is appropriate to treat it. Fever, a floating pulse, and a slightly yellow tongue coating indicate that the dryness-heat was overwhelming. Therefore, a little amount of bò he and chán yī were added to scatter wind and dissipate heat. Lián qiào and zhú yè were added to clear upper jiao heat. Qián hú and jú hóng were added to rectify the lung and relieve cough since the patient was coughing and his lung qi failed to descend. He was thirsty yet did not desire much water indicating that the consumption of fluids was not serious. Therefore, shā shēn and lí pí were removed and huā fĕn and lú gēn were added to clear heat and generate fluids. With these medicinals combined, the formula has the function of clearing dryness-heat and moistening the lung and relieving cough.1

Qīng Zào Jiù Fèi Tāng 清燥救肺汤DrynessEliminating and Lung-Rescuing Decoction Source Text Precepts for Physicians (Yī Mén Fă Lǜ, 医门法律)

Formula Ingredients

1 Cao Bin-zhang. Great Achievement of Tradition Chinese Medicine-Vol. 8-Medical Cases and Records 中国医学⼤成八·医案医话分册. Beijing: China Press of Traditional Chinese Medicine; 1997.

Preparation and Administration Cook the ingredients with 1 bowl of water until the liquid is reduced to 60% of the original volume. Take the strained decoction while warm 2-3 times daily. (Modern use: cook the ingredients, take the strained decoction while warm frequently.)

Formula Indications

Qīng Zào Jiù Fèi Tāng is indicated for the pattern of warm-dryness damaging the lung, complicated by damage to both qi and yin. The symptoms are fever, headache, coughing with no sputum, labored breathing, dryness of the nose and throat, vexation, thirst, chest fullness and hypochondriac pain. The tongue body is dry with scanty tongue coating, and the pulse is deficient, big, and rapid.

Analysis of Fundamental Pattern Pathogenesis Qīng Zào Jiù Fèi Tāng is designed for severe cases of warm-dryness injuring the lung. The autumn season is dry, and therefore, dryness-heat attacks the lung damaging both qi and yin causing headache and fever. The lung fails to purify, nourish and direct qi downward, which is reflected by the coughing with no sputum, labored breathing, thirst and dryness of the nose. Basic Questions-Treatise on the Essentials of Supreme Truth says: “all kinds of qi stagnation belong to the lung”[3]. The failure of lung qi to descend causes oppression and fullness in the chest, even hypochondriac pain. The dry tongue with scanty tongue coating and the deficient, big, and rapid pulse indicate that warm-dryness has damaged the lung. The therapeutic principle is to clear, diffuse and moisten the lung, nourish yin and boost qi.

Formula Actions Relieves dryness and moistens the lung, nourishes yin and boosts qi.

Formula Analysis

Unique Combination Features This formula includes three therapeutic methods: diffusion, clearing, and moistening. It supplements both qi and yin, diffuses and scatters without consuming qi, clears heat without damaging the middle jiao, and enriches without cloying.

Further Clarification The use of calcined shí gāo in the source formula is meaningful. The Grand Compendium of Materia Medica says “in ancient times, shí gāo was broken into pieces the size of a bean and wrapped with silk to cook. Currently, physicians often use calcined or fried shí gāo with sugar in order to prevent shí gāo from damaging the spleen and stomach because of its cold nature”[4]. Yu Chang explained that his main purpose when formulating

Qīng Zào Jiù Fèi Tāng was to protect the stomach qi. The stomach earth is the mother of the lung metal. The lung yin has already been damaged by dryness and if the stomach also has been damaged by cold medicinals, as in this condition, the patient cannot live longer. Shí gāo is heavy and cold in nature and it enters the lung and stomach channels. Yu Chang uses the calcined shí gāo in a small dose to clear lung heat as well as to prevent damaging the stomach qi. There is another formula named Zhú Yè Huáng Lián Tāng in the same classic which also contains calcined shí gāo indicating that Yu Chang had mastered the skills of medicinal selection and formulation.

Formula Applications 1. Essential pattern differentiation Qīng Zào Jiù Fèi Tāng is commonly used to treat severe cases of warm-dryness injuring the lung. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula can be used in the following biomedically defined disorders when the patient shows signs of dryness-heat invading the lung, accompanied by damage to both qi and yin: pneumonia, bronchial asthma, acute and chronic bronchitis, bronchodilation and lung cancer.

Associated Formulas Shā Shēn Mài Dōng Tāng (Straight Ladybell and Ophiopogon Decoction, 沙参麦冬汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. For persistent fever and cough, it is required to add dì gŭ pí 3 qian (9 g). [Actions] Clears and nourishes the lung and stomach and engenders fluids to moisten dryness. [Applicable Patterns] Dryness damaging the lung and stomach yin. Symptoms include: a dry throat and mouth, or fever, dry cough, a red tongue with scanty tongue coating, and a thin, rapid pulse. Both Shā Shēn Mài Dōng Tāng and Qīng Zào Jiù Fèi Tāng contain sāng yè, mài dōng and gān căo. The functions of these two formulas are similar, but Shā Shēn Mài Dōng Tāng is formulated with yù zhú and shā shēn to treat dryness damaging the lung and stomach yin and fluids. Qīng

Zào Jiù Fèi Tāng is formulated with shí gāo and rén shēn to treat drynessheat attacking the lung with damage to both qi and yin.

Comparison & Contrast Sāng Xìng Tāng vs. Qīng Zào Jiù Fèi Tāng

Case Studies Expectoration of blood and cough Over the past few years Mr. Zou coughed with blood expectoration. He had a fever in the afternoon and a red face. His presentation was similar to a deficiency-consumption syndrome. However, when his coughing stopped, the blood expectoration also stopped; therefore, his situation wasn’t as harmful. In the spring, he unexpectedly contracted wind-cold which increased the blood expectoration and caused his situation to become more serious. His lips also became very red. It was caused by latent heat that

expressed when the external pathogen attacked the lung and stomach collaterals. Qīng Zào Jiù Fèi Tāng was used to treat the disease.1 1 Liu Bing-fan, Zhou Shao-ming. Essence of Ancient Books and Records of Famous Doctors in Hunan Province (Volume of Internal Medicine) 湖湘名医典籍精华(内科卷). Changsha: Hunan Science and Technology Press; 1999.

Comments: The patient’s old illness recurred when he contracted windcold. His expectoration of blood was very serious and his lips were very red. These were all caused by the years of expectoration of blood and coughing which consumed qi and blood. Yin-blood deficiency and consumption lead to the internal generation of deficiency-heat. When he contracted the windcold again, the pathogen turned into heat which harmed the blood and collaterals. Although the etiology of this case is different from external contraction of warm and dryness, both are syndromes of an external pathogen attacking the lung, lung fluid heated and yin-fluid consumed. Therefore, Qīng Zào Jiù Fèi Tāng was adopted to clear and vent heat, generate fluid and enrich yin, as well as moisten the lung to relieve cough.

Section 2 Yin-Enriching and DrynessMoistening Formulas Formulas that enrich yin and moisten dryness are applicable for patterns of internal dryness where the fluids of the zang-fu organs have been consumed and depleted. The most common signs and symptoms include coughing with scanty sputum, dry throat and mouth, thirst, belching, poor appetite, wasting-thirst, and constipation. Common medicinals used within the enriching yin and moistening dryness formulas include shā shēn, mài dōng, shēng dì, shú dì and xuán shēn. Common formulas in this category are Zēng Yè Tāng, Mài Mén Dōng Tāng, Yì Wèi Tāng, Yăng Yīn Qīng Fèi Tāng and Băi Hé Gù Jīn Tāng.

Zēng Yè Tāng 增液汤Humor-Increasing Decoction Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration

Cook the ingredients with 8 cups of water and reduce it down to 3 cups. For patients with a dry mouth, take the entire decoction at once. Repeat this process if the patients do not have a bowel movement (Modern use: prepare the ingredients as a decoction for oral use).

Formula Indications Zēng Yè Tāng is indicated for yangming warm-febrile disease with fluid inadequacy and constipation. The symptoms are constipation and thirst. The tongue is red and dry, and the pulse is thin and rapid or deep and forceless.

Analysis of Fundamental Pattern Pathogenesis Constipation as a symptom of yangming warm-febrile disease is commonly caused by the binding of heat or drying up of fluids. For an excess pattern with intense heat and binding of heat, Dà Chéng Qì Tāng should be selected to drastically purge and preserve yin. However, in cases where yin and body fluids have already been severely damaged due to heat and dryness, “the boat cannot steer because there is no water; the dry and accumulated stool cannot be discharged”[5] as stated in Systematic Differentiation of Warm Diseases. In this condition, it is necessary to employ the therapeutic method of “increasing the fluids to float the boat”[6]. The constipation that is treated by this formula is caused by febrile disease which consumes fluids and leads to yin deficiency and drying of the fluids that moisten the intestines and facilitate the passage of stool. As yin-fluids become depleted, they are unable to rise to the mouth, causing thirst. A dry, red tongue and thin, rapid pulse reflect internal heat from yin deficiency and a deep and forceless pulse indicates interior deficiency. The appropriate therapeutic method is to increase body fluids in order to moisten dryness.

Formula Actions Increases body fluids to moisten dryness.

Formula Analysis

Formula Applications 1. Essential pattern differentiation Zēng Yè Tāng is a common formula prescribed to treat constipation caused by intestinal dryness and fluid depletion. It is also a primary formula used to treat yin deficiency and fluid depletion caused by internal damage. This clinical pattern is marked by:

2. Modern applications This formula can be used in the following biomedically defined disorders when the patient shows signs of yin-fluid deficiency: chronic pharyngitis, recurrent oral ulcer, diabetes, sjogren syndrome, and fissure, and chronic periodontitis.

Associated Formulas Zēng Yè Chéng Qì Tāng (Humor-Increasing and Qi-Guiding Decoction, 增液承⽓汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Enriches yin and increases fluid, and discharges heat to promote defecation. [Applicable Patterns] Heat binding and yin deficiency. Symptoms include: obstruction of dry stool that cannot be moved by purging, distention and fullness of the stomach cavity and abdomen, dry mouth and lips, a red tongue with yellow tongue coating, and a thin, rapid pulse. Both Zēng Yè Tāng and Zēng Yè Chéng Qì Tāng were created by Wu Ju-tong and are used to treat constipation due to yin deficiency associated with warm disease. This condition is described as “the boat cannot steer because there is no water”[7], therefore, these two formulas are used to increase the fluids in order to “float the boat”. Systematic Differentiation of

Warm Diseases indicates that yangming warm disease manifests as constipation caused by the exhaustion of fluids-“the boat cannot steer because of there is no water; the dry and accumulated stool cannot be discharged”[5]. In this condition, Zēng Yè Tāng should be used to increase fluids. However, if the accumulated stool cannot be discharged, and Zēng Yè Tāng is not strong enough for such severe dryness, it is then suitable to use Zēng Yè Chéng Qì Tāng taken slowly. The main focus of Zēng Yè Tāng is to nourish and moisten in order to treat severe fluid consumption with mild dryness accumulation. Zēng Yè Chéng Qì Tāng incorporates both moistening and purging therapeutic methods designed for severe fluids consumption and dryness accumulation. When treating these two patterns clinically, it is important to properly differentiate between a moderate and an urgent condition.

Case Studies Constipation A 45-year-old female had habitual constipation for more than one year because of functional uterine bleeding. She could defecate once every two days but that was only with the help of phenolphthalein tablets. She also had vexing heat, was thirsty, had a bitter taste in the mouth, dry eyes, dizziness, ringing in the ears, and a poor appetite. She was diagnosed with constipation due to yin deficiency and blood dryness. Zēng Yè Tāng, with additions, was prescribed. The ingredients were xuán shēn 15 g, mài dōng 15 g, shú dì 15 g, nǚ zhēn zĭ 15 g, mò hàn lián 15 g, ē jiāo 10 g, shēng dà huáng 5 g. The patient was advised to take three doses, prepared as a decoction. After taking the first dose, the patient could defecate once a day and felt relief from the vexing heat. Her appetite improved after taking three doses. Then after taking another three doses, the constipation was relieved.1

Comments: This case of constipation was caused by functional uterine bleeding. The symptoms were related to yin deficiency and blood dryness. Therefore, Zēng Yè Tāng was adopted to nourish yin and moisten dryness. In addition, Èr Zhì (nǚ zhēn zĭ and mò hàn lián) was added along with ē jiāo to enrich yin-blood and stanch bleeding, and shēng dà huáng to clear heat and relax the bowels. The medicinals matched the symptoms, so the formula’s effect was excellent. 1 Dong Jian-hua. Clinical Experiences 临证治验. Beijing: China Friendship Publishing Company; 1986.

Mài Mén Dōng Tāng 麦门冬汤Ophiopogon Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration The source text advises to cook the ingredients with 1 dou and 7 sheng of water until the liquid is reduced to 6 sheng. Take 1 sheng of the warm, strained decoction three times during the day and once at night. (Modern use: prepare it as a decoction).

Formula Indications Mài Mén Dōng Tāng is indicated for lung wĕi (lung atrophy, 肺痿) due to deficiency-heat. The symptoms are coughing, labored breathing, throat discomfort, sputum that is difficult to expectorate, coughing up or spitting saliva, dry mouth and throat and a feverish feeling in the palms and soles.

The tongue is red with scanty tongue coating, and the pulse is deficient and rapid. Mài Mén Dōng Tāng is also indicated for stomach yin deficiency with vomiting, poor appetite, hiccup, thirst and dry throat. The tongue is red with a scanty tongue coating, and the pulse is deficient and rapid.

Analysis of Fundamental Pattern Pathogenesis This formula treats lung wĕi due to deficiency-heat which is caused by lung and stomach yin deficiency with upward reversal of qi and fire. Although the symptoms are primarily related to the lung, the condition is actually caused by the heat from stomach yin deficiency. The earth is the mother of metal and the stomach governs the body fluids. Stomach fluid deficiency causes lung fluid deficiency which further develops into both lung and stomach yin-fluid deficiency. In the condition of lung and stomach yin deficiency, fluids are scorched by deficiency-fire creating sputum, and there is a failure of lung qi to purify. This manifests a cough with ascending counterflow qi and spitting up saliva. Since the throat is the portal of the lung and stomach, lung and stomach yin deficiency often results in fluid failing to flow upwards; and as a result, patients experience a dry mouth and throat as well as a feverish feeling in the palms and soles due to exuberant internal deficiency-heat. Stomach yin deficiency may lead to reversal qi flowing upwards causing vomiting. The red tongue body with scanty tongue coating and a deficient, rapid pulse are typical signs of yin deficiency with internal heat. The appropriate therapeutic methods are to clear and nourish the lung and stomach, direct counterflow downward, and lower qi.

Formula Actions

Clears and nourishes the lung and stomach, directs counterflow downward and lowers qi.

Formula Analysis

Formula Applications 1. Essential pattern differentiation Mài Mén Dōng Tāng treats coughing or vomiting caused by lung and stomach yin deficiency with counterflow of the qi dynamic. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of lung and stomach yin deficiency with counterflow of fire and qi: chronic bronchitis, bronchodilation, chronic pharyngitis, acute silicosis and tuberculosis; it is also used in the following biomedically defined disorders when the patient shows signs of stomach yin insufficiency and vomiting due to qi counterflow: gastroduodenal ulcer, chronic atrophic gastritis, vomiting during pregnancy.

Case Studies Lung wĕi Zha, 24 years old, had a thready pulse, feverish feeling, noisy breathing, and insomnia at night. Previous overuse of dispersing medicinals resulted in qi leakage and yang damage which in turn caused lung wĕi. Zhong-jing used stomach-supplementing medicinals in order to supplement the mother to save the child and to generate qi. The prescription was Mài Mén Dōng Tāng from the Essentials from the Golden Cabinet.1

Comments: Yu Chang said: “Deficient fire flames upward to harass the lung whenever the stomach fluid goes dry. If cool and cold medicinals are taken, the fire will flame upward. If one only contends with the fire and forgets to treat the stomach as the mother qi phase to the lung, the treatment is not correct.” Treatise on Blood Disease (Xuè Zhèng Lùn, ⾎证论) explains that Mài Mén Dōng Tāng raises the center qi, generates fluids, and transports stomach fluid up to the lung. Upon this, the fire qi will then descend and the fluids regenerate. When the fire is cleared, the lung will have relief and become harmonized. The qi will then return to normal.

Yì Wèi Tāng 益胃汤Stomach-Boosting Decoction Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration The source text states to cook the ingredients with 5 cups of water until the decoction is reduced to 2 cups. Take the strained decoction twice a day and then decoct the dregs again and take 1 cup. (Modern use: prepare as a decoction). 1 Written by Ye Tian-shi, and edited by Huang Ying-zhi. Guide to Clinical Practice 临证指南医 案. Beijing: Chinese Traditional Chinese Medicine Press; 1999.

Formula Indications Yì Wèi Tāng is indicated for stomach yin damage. The symptoms include a burning sensation and dull pain in the gastric cavity, hunger with

no desire to eat, dry mouth and throat, and dry stool. The tongue is red with a scanty coating, and the pulse is thready and rapid.

Analysis of Fundamental Pattern Pathogenesis The stomach is yang earth. It likes moistness and dislikes dryness. It governs the intake of food and drinks and the stomach qi governs descent. The consumption of stomach yin and internal deficiency-heat is often caused by the following conditions:

Stomach yin deficiency causes the collaterals to lose nourishment and produce dull pain in the stomach cavity. The heat that results from yin deficiency results in burning pain within the stomach cavity. When the stomach fails to properly govern the intake of food and drink, hunger with no desire to eat will manifest. Deficient stomach yin-fluids fail to nourish the mouth, throat, and large intestine. As a result, the clinical manifestations of this condition include symptoms such as dry mouth and throat, and dry stool. A red tongue body with a scanty tongue coating and a deficient, rapid pulse are typical signs of internal heat caused by yin deficiency. The stomach is the reservoir of water and grain, and the twelve channels qi are rooted in the stomach. Therefore, if the stomach yin can recover, the stomach qi will descend to improve poor appetite. The appropriate therapeutic method is to promote fluid production with sweet-cooling, yin-nourishing, and stomachboosting medicinals.

Formula Actions Nourishes yin and boosts the stomach.

Formula Analysis

Formula Applications 1. Essential pattern differentiation Yì Wèi Tāng is commonly used to nourish the stomach yin. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is commonly used in the following biomedically defined disorders when the patient shows signs of stomach yin deficiency: chronic

gastritis, diabetes and infantile anorexia.

Case Studies Thirst and profuse sweating This is a case of Dr. Wu Ju-tong’s clinical experience in the Qing Dynasty. The patient’s pulse was thready and rapid but not floating. The condition was a febrile disease with internal deficiency and the patient was very thirsty so he drank a lot and sweat profusely. Yù Nǚ Jiān (Jade Lady Decoction) was adopted to treat the disease. The prescription included: zhī mŭ 4 qian, shēng shí gāo 1 liang, sāng yè 3 qian, mài dōng 5 qian, shēng dì 5 qian, jīng mĭ 1 pinch and gān căo 3 qian. The patient returned the next day after taking the prescribed Yù Nǚ Jiān and all the symptoms were relieved. Yù Nǚ Jiān could treat his xiāo kĕ (wasting-thirst, 消渴). Since his stool was thin and unformed, mŭ lì was added as it can both protect yin and astringe the lower. The prescription then included: mŭ lì 1 liang, shēng shí gāo 5 qian, zhī mŭ (dry-fried) 2 qian, mài dōng 5 qian, shēng dì 5 qian, jīng mĭ 1 pinch and zhì gān căo 5 qian. Used in combination with Yì Wèi Tāng the patient recuperated.1 Comments: Wu Ju-tong said he named the decoction as “Yì Wèi Tāng” because it is beneficial to the stomach function. The stomach is yin in its form but yang in its function. Since all the twelve channels receive qi from the stomach, when the stomach yin recovers, the stomach qi will descend and the appetite will improve and the yin of the twelve channels will all also recover. Medicinals that are sweet and cool need to be used to recover yin. The patient had constitutional yin deficiency and profuse sweating had damaged fluids. Therefore, his yin needed to be restored.

Yăng Yīn Qīng Fèi Tāng 养阴清肺汤YinNourishing and Lung-Clearing Decoction Source Text Jade Key to the Secluded Chamber (Zhòng Lóu Yù Yào, 重楼⽟钥) 1 Written by Dai Tian-zhang, edited by He Lian-chen. Warm Febrile Diseases Revised Edition 重 订广温热论. Fuzhou: Fujian Science & Technology Publishing House; 2005.

Formula Ingredients

Preparation and Administration Prepare the ingredients as a decoction. For an average case, take one dose daily and for a serious case, take two doses daily.

Formula Indications

Yăng Yīn Qīng Fèi Tāng is indicated for diphtheria due to yin deficiency and dryness-heat. The symptoms include white, curd-like spots in the throat that are hard to scrape off, a swollen and sore throat, with or without fever at the beginning of the disease, dry nose and lips, with or without coughing, raspy breathing resembling wheezing, and a rapid, forceless or thin, rapid pulse.

Analysis of Fundamental Pattern Pathogenesis Diphtheria usually occurs in those with constitutional yin deficiency and internal clumping of heat. Dry qi accompanies epidemic toxins that further attack the body and scorch the fluids which results in epidemic toxic heat fuming upward. As noted in the first volume of the Jade Key to the Secluded Chamber: “this condition usually arises in those with lung and kidney deficiency when they are exposed to prevalent dry qi or take too much acrid and spicy food.”[8] The throat connects with the lung and the shaoyin kidney channel passes through the throat and links with the tongue. Thereby, lung and kidney yin deficiency may cause deficiency fire flaming upward to the throat. In this scenario it is accompanied with epidemic dryheat toxins attacking upwards and lung qi failing to purify. As a result, the patient develops white, curd-like spots in the throat, swollen and sore throat, with or without coughing, raspy breathing resembling wheezing, etc. Dry nose and lips, a rapid, forceless or thin, rapid pulse are typical signs of dryness-heat damaging fluid and deficiency of vital qi with toxin accumulation. The first volume of Jade Key to the Secluded Chamber describes suitable therapeutic strategies “when treating this disorder, make sure the location is the lung and kidney. In general one must nourish yin and clear lung heat while the governing strategy is to combine this with acrid, cooling, and dispersing”[9].

Formula Actions Nourishes yin and clears lung heat, resolves toxins and improves the condition of the throat.

Formula Analysis

Formula Applications 1. Essential pattern differentiation

Yăng Yīn Qīng Fèi Tāng is commonly used to treat diphtheria caused by yin deficiency and dryness-heat. This clinical pattern is marked by:

It is contraindicated to release the exterior when treating diphtheria and especially to induce sweating with acrid-warm medicinals. Instructions following the source formula say “if the patient has internal heat or fever, it is not necessary to use medicinals that release the exterior, only use this formula and the heat will be relieved consequently”[10]. 2. Modifications

3. Modern applications This formula is commonly used in the following biomedically defined disorders when the patient shows signs of yin deficiency and dryness-heat: acute tonsillitis, acute pharyngitis, and nasopharyngeal carcinoma.

Case Studies Throat bì (pharyngitis) A female patient developed throat bì (pharyngitis). Her throat was so swollen and painful that she could hardly drink even one drop of water or take any medicine. Her disease came on very quickly and her throat became blocked. Her lips were dark in color, both eyes and face were swollen, and the phlegm was so heavy that it seemed that she was going to suffocate. Her

condition was so serious that the hospitals refused to receive and treat her. So she then turned to me. I told her that the heat toxin was very intense and the toxin of the swelling was very serious, but it was not a fatal disease. She could not ingest medicine because of the throat bì. So to start, I put a pellet of Léi Shì Liù Shén Wán under her tongue and moistened it with a little warm water. On the second day, she could drink a little tea, so I added Yăng Yīn Qīng Fèi Tāng to the tea. The amount of bò he was half the weight of the original formula and shēng dì was doubled the original amount. After seven days, the symptoms disappeared. Her qi and mind became as calm and clear as a normal person.1 Comments: Throat bì manifests in the upper aspect of the body due to the pathogenesis of lung dryness-heat and yin deficiency complicated by an acquired toxin. Yăng Yīn Qīng Fèi Tāng is used to treat the root and branch simultaneously.

Băi Hé Gù Jīn Tāng 百合固⾦汤Lily Bulb MetalSecuring Decoction Source Text Medical Theory of Master of Meditation Room (Shèn Zhāi Yí Shū, 慎斋 遗书)

Formula Ingredients

1 Ran Xue-feng. Ran Xue-feng Medical Records 冉雪峰医案. Beijing: People’s Medical Publishing House; 1962.

Preparation and Administration Prepare as a decoction.

Formula Indications

Băi Hé Gù Jīn Tāng is indicated for a pattern of lung-kidney yin deficiency with deficiency fire flaming upward. The symptoms are coughing, labored breathing, blood in the sputum, dry and sore throat, dizziness and blurred vision, afternoon tidal fever. The tongue is red with a scanty coating, and the pulse is thready and rapid.

Analysis of Fundamental Pattern Pathogenesis This pattern results from yin deficiency of the lung and kidney. The lung is the mother of the kidney so lung deficiency often affects the kidney to cause yin deficiency of both the lung and kidney due to protracted disease. Yin deficiency leads to internal heat and deficiency fire flaming upward, causing the failure of the lung to purify and descend, which produces coughing and labored breathing. Deficiency fire scorches body fluids and causes a dry, sore throat and an afternoon tidal fever. Vessels are scorched which causes blood in the sputum. Suitable therapeutic methods include nourishing the yin-blood of the lung and kidney combined with clearing heat, dissolving phlegm and relieving cough. The purpose is to treat the root and branch simultaneously.

Formula Actions Enriches and nourishes the lung and kidney, relieves cough and dissolves phlegm.

Formula Analysis

Continued

Formula Applications 1. Essential pattern differentiation This formula is commonly used to treat lung-kidney yin deficiency with deficiency fire flaming upward to cause coughing with blood in the sputum. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is commonly used in the following biomedically defined disorders when the patient shows signs of lung-kidney yin deficiency with deficiency fire flaming upward: tuberculosis, chronic bronchitis, expectoration of blood caused by bronchiectasis, chronic pharyngolaryngitis, and spontaneous pneumothorax.

Associated Formulas Bŭ Fèi Ē Jiāo Tāng (Lung-Supplementing Donkey-Hide Gelatin Decoction, 补肺阿胶汤) [Source] Key to Diagnosis and Treatment of Children’s Diseases (Xiăo Ér Yào Zhèng Zhí Jué, ⼩⼉药证直诀) [Ingredients]

[Preparation and Administration]

Grind the ingredients into powder, use 1 to 2 qian (6 g) powder at a time and prepare the powder as a decoction, take the warm decoction after meals. [Actions] Supplements yin and boosts the lung, clears heat to stanch bleeding. [Applicable Patterns] Lung heat from yin deficiency pattern in children. Symptoms include: coughing, labored breathing, dry throat, sound in the throat, or blood in the sputum, a red tongue body with a scanty tongue coating, and a thready, rapid pulse. Both Băi Hé Gù Jīn Tāng and Bŭ Fèi Ē Jiāo Tāng can be used to treat heat from lung deficiency. However, the former is mainly used to treat lung and kidney yin deficiency with deficiency fire flaming upward which leads to coughing with sputum and blood. It focuses on nourishing the kidney and enriching yin to moisten the lung, as well as, clearing heat and dissolving phlegm. The latter is often used to treat lung heat from yin deficiency causing cough in children. It focuses on boosting lung yin, clearing the lung, dissolving phlegm, and relieving cough.

Case Studies Lung consumption Mr. You, 25 years old. He once suffered lung consumption that was recently aggravated following his wedding last winter and from drinking alcohol during the Spring Festival in the following months. The aggravation caused him to expectorate blood. His condition also was accompanied by mental fatigue, shortness of breath, poor appetite, and a loss of body weight.

His tongue had a scanty coating and His pulse was weak and rapid. He was initially diagnosed with spleen qi deficiency unable to contain blood. He took Bŭ Zhōng Yì Qì Tāng and the expectoration of blood reduced, but didn’t stop. Upon careful re-examination, it was revealed that the patient’s condition began following his marriage. The signs and symptoms include red cheekbones, night sweat, five center heat, and a dry pharynx with hoarseness. The pulse was weak, thready, and rapid. The tongue was red with scanty coating. These were the symptoms of yin deficiency and lung dryness. So, it was better to adopt Băi Hé Gù Jīn Tāng and the effect was very obvious.1 Comments: This formula is consistent with the concept of mutual generation between metal and water, as well as, the harmony of qi and blood. The book Elaboration on the Asthenic Disease (Xū Sŭn Qĭ Wēi, 虚损 启微) said: “kidney fluid cannot control fire; therefore, it restricts metal. Yin essence cannot change into qi; therefore, dryness disease occurs. Fire has left its original place so pure sweet and cold medicinals are taken to nourish it.” Ye Tian-shi used lung medicines to treat enduring cough to little effect. The rapid pulse is treated by a combination of medicinals that nourish metal and water such as shú dì, shēng dì, bĕi shā shēn, tiān dōng and mài dōng.

Summary Dryness-relieving formulas contain eight formal formulas and four associated formulas. They can be divided to two types:

● formulas that relieve external dryness by light diffusion ● yin-enriching and dryness-moistening formulas 1. Formulas that relieve external dryness by light diffusion

1 Shi Yu-guang. Contemporary Famous Doctors’ Clinical Essence-Book of Blood Disease 当代 名医临证精华·⾎证专辑. Beijing: TCM Classics Publishing House; 1992.

These formulas are applicable to external dryness patterns. Xìng Sū Săn gently disperses cool-dryness, regulates the lung qi, and dissolves phlegm. It is applicable to external contraction of cool-dryness as well as, wind-cold lung damage and cough. Both Sāng Xìng Tāng and Qīng Zào Jiù Fèi Tāng can treat warm-dryness. Sāng Xìng Tāng clears and disperses warm-dryness. It may be applied for an external attack of warm-dryness and mild symptoms caused by scorched lung fluid. The main points of their syndrome differentiation are: mild heat, dry cough with little phlegm, and a rapid right hand pulse. Qīng Zào Jiù Fèi Tāng clears dryness and moistens the lung, enriches yin, and boosts qi. It is applicable to dryness-heat damaging the lung, as well as, serious damage to both qi and yin. The main points of their syndrome differentiation are: body heat, dry cough, counterflow of qi with labored breathing, and a deficient, rapid pulse. 2. Yin-enriching and dryness-moistening formulas They are applicable for patterns of internal dryness. Zēng Yè Tāng is a tonic in function but a laxative in use. It increases body fluids to moisten dryness. The major applications of this formula are to treat yangming warm disease and constipation caused by the consumption and desiccation of fluids and intestine dryness. Since this formula is good at nourishing yin and increasing fluids, it is also usually used to treat syndromes such as internal harm of yin deficiency and fluid depletion. Mài Mén Dōng Tāng nourishes the lung and stomach, directs counterflow downward, and descends qi. Its major applications are treating deficiency-heat lung wĕi (atrophy) and stomach yin insufficiency. Yì Wèi Tāng specializes in enriching yin to boost the stomach. Its major applications are treating poor appetite, thirst, and dry throat caused by stomach yin injury. Yăng Yīn Qīng Fèi Tāng is better to

enrich yin and clear lung and to resolve toxins and relieve the throat. It is an effective formula used to treat diphtheria and a swollen, painful throat caused by yin deficiency and dryness-heat. Băi Hé Gù Jīn Tāng enriches and nourishes the lung and kidney, relieves cough, and dissolves phlegm. It is best applied for treating coughs with bloody sputum caused by lung and yin deficiency as well as deficiency fire flaming upward.

Questions 1.What are the differences and similarities of treating methods between external dryness and internal dryness, as well as, those between cool dryness and warm dryness? 2. Xìng Sū Săn is mainly applied for an external contraction of cool dryness. Why should it be combined with warm, drying medicinals? 3.What are the main indications that Qīng Zào Jiù Fèi Tāng are applicable for? Why is the dosage of shí gāo and mài dōng less than that of sāng yè? 4.The indication of Mài Mén Dōng Tāng is deficiency-heat. Why is sweet, warm rén shēn and warm, dry bàn xià combined in the formula? 5.Compare the differences and similarities between Yăng Yīn Qīng Fèi Tāng and Băi Hé Gù Jīn Tāng according to ingredients, actions, and indications?

Endnotes: [1] 燥淫于内，治以苦温，佐以⽢⾟ [2] 轻药不得重⽤，重⽤必过病所 [3] 诸⽓膹郁，皆属于肺 [4] ⽯膏，古法惟打碎如⾖⼤，绢包入汤煮之，近⼈因其寒，⽕煅 ⽤过，或糖拌炒过，则不妨脾胃 [5] ⽔不⾜以⾏⾈，⽽结粪不下者 [6] 增⽔⾏⾈ [7] 无⽔⾈停 [8] 缘此证发于肺肾，凡本质不⾜者，或遇燥⽓流⾏，或多食⾟热 之物，感触⽽发 [9] 不外肺肾，总要养阴清肺，兼⾟凉⽽散为主 [10] 如有内热及发热，不必投表药，照⽅服去，其热⾃除

CHAPTER 14 DampnessDispelling Formulas Dampness dispelling formulas utilize dampness-dispelling medicinals as key components. They have the therapeutic actions to dispel dampness and promote urination, relieve strangury, and direct the turbid downward. The therapeutic method to treat dampness was historically referred to as the “dispersion method”, one of the eight treatment methods recorded in ancient literature. Dampness is either an external or internal pathogen. External dampness is mainly due to living in a humid place, staying outside in misty and foggy weather, standing in or wading across a body of water, and wearing wet clothes after sweating. When external dampness invades the body’s exterior, channels and collaterals are affected. The manifestations include aversion to co1d with fever, distending sensation in the head, heavy body, aching joints, facial edema, and so on. The pattern of internal dampness is mainly caused by eating too much cold, raw food, oily, sweet food, and drinking too much alcohol. When internal dampness is produced, the zang-fu organs become impaired manifesting abdominal distention, nausea, vomiting, diarrhea, edema, dysuria, jaundice, wĕi and bì syndrome, and so on. Furthermore, the body’s exterior and the zang-fu organs are interior-exteriorly related. External dampness can penetrate the zang-fu organs, while internal dampness can spread into the exterior. Consequently, both external

dampness and internal dampness could have a mutual affect in certain disease patterns. Dampness often invades the human body together with wind, cold, summerheat, and/or heat. However, body constitutions vary person to person and disease locations vary part to part. Thus once dampness enters the body it is either transformed into cold-dampness or damp-heat. This is the reason that diseases associated with dampness are always complicated and the therapeutic methods to treat dampness are various. Generally, one might mildly release dampness by the sweatpromoting method when the dampness is located in the upper part of the body. One might dry and remove dampness with aromatic and bitter medicinals or percolate and drain dampness with bland medicinals when the dampness is located in the lower part of the body or internal regions. One might expel and eliminate dampness with the purgative method when the dampness has accumulated in excess and there is sufficient qi. One might warm yang to dispel dampness for the pattern of dampness transformed into cold-dampness. One might clear heat and dispel dampness for the pattern of dampness transformed into damp-heat. One might dispel dampness and reinforce zheng qi for the pattern of qi deficiency with excessive dampness. Dampness-dispelling formulas are therefore categorized into five types:

● dampness-drying and stomach-harmonizing formulas ● heat-clearing and dampness-dispelling formulas ● urination-promoting and dampness-percolating formulas ● cold-damp-warming and resolving formulas ● wind-dispelling and dampness-overcoming formulas

Formulas to expel water with purgatives are introduced in the purgative formulas. Dampness and water have different names but are the same material. They are closely related to the lung, spleen and kidney. Spleen deficiency gives rise to dampness, kidney deficiency leads to water diffusion, and lung failing to diffuse and govern descent results in the misdistribution of fluid and water. Therefore, the treatment for dampness is always combined with methods to regulate the zang-fu organs. The sanjiao and the bladder also have functions related to water and dampness. The sanjiao, as the water passage, is an organ in charge of water circulation. Disorders of the sanjiao may disturb water distribution. Dysfunction of the bladder’s qi transformation may disturb urination. Methods that promote healthy sanjiao and bladder function are beneficial to remove dampness. Dampness is a yin pathogen that is characteristically heavy, turbid and lingering. It tends to obstruct qi movement causing poor transportation and transformation of dampness. Dampnessdispelling formulas often contain qirectifying medicinals because dampness is removed in the process of qi dispersion. Dampness-dispelling formulas should be applied cautiously to those patients that are weak from yin and fluid deficiency, weak from long-term disease, or are pregnant. They are generally composed of aromatic, dry and draining medicinals that consume yin fluid.

Section 1 Dampness-Drying and Stomach-Harmonizing Formulas

Dampness-drying and stomach-harmonizing formulas are used for patterns of internal dampness and turbidity accumulation that lead to disharmony of the spleen and stomach. The signs and symptoms include abdominal pĭ and fullness, belching, acid swallowing, vomiting, diarrhea, poor appetite, fatigue, and so on. Cāng zhú, huò xiāng, hòu pò and bái dòu kòu are medicinals that dry dampness with a bitter flavor and warm property and remove dampness with aroma. Medicinals that rectify qi and harmonize the center, such as shā rén and chén pí, are often included within these formulas. Píng Wèi Săn and Huò Xiāng Zhèng Qì Săn are representative formulas.

Píng Wèi Săn 平胃散Stomach-Calming Powder Source Text Concise Formulas to Aid Majorities (Jiăn Yào Jì Zhòng Fāng, 简要济 众⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into powder. One dose is approximately 4-6 g. The powder is to be taken with a decoction of shēng jiāng and dà zăo. It can

also be prepared as a decoction.

Formula Indications This formula is indicated for patterns of dampness accumulation in the spleen and stomach. The symptoms are abdominal distension and fullness, poor appetite, tastelessness, nausea, vomiting, belching, acid swallowing, heavy limbs, mental fatigue, lack of strength, somnolence and diarrhea. The tongue coating is white, greasy and thick. The pulse is slow.

Analysis of Fundamental Pattern Pathogenesis This is a pattern caused by dampness accumulation in the spleen and stomach. Spleen pertains to the earth of taiyin, is localized in the middle jiao and governs transportation and transformation. It is adverse to humidity and prefers dryness. When dampness accumulation blocks the middle jiao, the result is failure of transportation and transformation marked by abdominal distension and fullness, poor appetite and tastelessness. Additionally, the stomach qi might fail to descend. Counterflow of the stomach qi leads to nausea, vomiting, belching, and acid swallowing. Dampness is a yin pathogen that is heavy and lingering by its nature. Therefore, dampness accumulation in the body leads to heavy sensation in the limbs, lassitude, and somnolence. Dampness entering the intestine results in diarrhea. The therapeutic principles are to dry dampness and to activate the spleen as the primary function and move qi and harmonize the stomach as the secondary function. The ability to remove dampness is increased when qi moves smoothly.

Formula Actions

Dries dampness and activates the spleen, moves qi and harmonizes the stomach.

Formula Analysis

Continued

Unique Combination Features This formula combines medicinals that dry dampness with ones that move qi. It is focused on drying dampness. This formula dries dampness to rebuild the normal function of the spleen and moves qi to dispel dampness. The spleen and stomach will be harmonious when dampness is removed and qi moves smooth.

Formula Applications 1. Essential pattern differentiation Píng Wèi Săn is a basic formula applicable to the pattern of dampness stagnation in the spleen and stomach. This clinical pattern is marked by:

● abdominal distension and fullness ● thick and greasy tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of dampness stagnation in the spleen and stomach: chronic gastritis, functional disorders of the gastrointestinal tract, and gastric and duodenal ulcer. 4. Cautions and contraindications This formula is not applicable for patients with yin deficiency, qi stagnation, or deficiency of the spleen and stomach because it is acrid, bitter, warm, and dry.

Associated Formulas Bù Huàn Jīn Zhèng Qì Săn (Precious Than Gold Qi-Correcting Powder, 不换⾦正⽓散)

[Source] Simple Formulas (Yì Jiăn Fāng, 易简⽅) [Ingredients]

[Preparation and Administration] Cut the medicinals into pieces. One doge is 4 qian (12 g). Add 1 zhan of water and decoct it with 3 pieces of shēng jiāng until 60% water remain, remove the dregs and take it warm. [Actions] Releases the exterior and removes dampness, harmonizes the stomach to arrest vomiting. [Applicable Patterns] Dampness accumulation with an exterior-cold pattern. Symptoms include: vomiting and abdominal distention, aversion to co1d with fever, huò luàn (霍乱)1, inability to acclimate, and a white and greasy tongue coating. 1 Mostly in ancient records, it refers to severe vomiting and diarrhea.

Chái Píng Tāng (Bupleurum Stomach-Calming Decoction, 柴平汤) [Source] The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书) [Ingredients]

[Preparation and Administration] Add 2 zhong of water and decoct it with shēng jiāng and dà zăo. [Actions] Harmonizes shaoyang, dispels dampness and harmonizes the stomach. [Applicable Patterns] Dampness malaria. Symptoms include: general pain, heavy limbs, more chills than fever, and a soggy pulse. Bù Huàn Jīn Zhèng Qì Săn contains huò xiāng and bàn xià. Compared to Píng Wèi Săn, it has a stronger effect to harmonize the stomach by drying dampness and to arrest vomiting by directing counterflow downward. Additionally, it can release the exterior. Chái Píng Tāng is composed of Xiăo Chái Hú Tāng and Píng Wèi Săn. It can harmonize the shaoyang, dry dampness, and dissolve phlegm to harmonize the stomach. It is used to treat dampness malaria due to phlegmdampness stagnation in the shaoyang for patients who have excessive phlegm-dampness and have contracted exogenous pathogens.

Case Studies Pĭ syndrome Doctor Yu Heng-de once treated an obese patient who was over thirty years old. During the summer and autumn, police officials forced him to work hard. When winter arrived, he was diagnosed with pĭ. The symptoms were chest distress caused by adverse qi flowing from the hypochondrium and the inability to lie down due to stomach fullness. He had been treated with dredging and dissipating medicinals by various physicians with no

apparent effect. In early November (lunar calendar), doctor Yu took his pulse. It was floating, surging, wiry and choppy just distal to the guān position and deep and hidden proximal to the guān. His was a pattern of sticky phlegm accumulation in the diaphragm due to the spleen qi overacting and thereby inhibiting the free flow the liver. Emetic therapy could be applied to remove liver qi constraint. However, because of the descending and sinking tendency of winter, it was not carried out. Instead, medicinals that eliminate phlegm, soothe liver qi, and purge excessive spleen and stomach qi were applied. Doctor Yu prescribed Píng Wèi Săn with bàn xià, qīng pí, fú líng, chuān xiōng, lóng dăn căo, xiāng fù, shā rén, chái hú, huáng lián, and guā lóu rén. After taking the formula, the symptoms reduced forty percent. He was completely cured the following early February after the application of some emetics that “empty the warehouse (the stomach)”.1 1 Jiang Quan. Classified Case Records of Famous Physicians 宣统元年.名医类案. Shanghai: Shanghai Book Bureau, first year of Xuan Tong.

Comments: The patient is in his thirties and obese. This is congruent with an old saying that obesity precipitates excessive dampness. Chest distress caused by the adverse flow of qi from the hypochondrium, stomach fullness that prevents him from lying down, and the floating, surging, wiry, and choppy pulse distal to the guān confirm pĭ syndrome. His condition is the result of spleen deficiency and liver constraint due to sticky phlegm in the diaphragm. Routine treatment is to eliminate phlegm and regulate the liver by emetic therapy. However, the approach was changed because the earth element of the middle jiao weakens in the winter. Therefore, medicinals that dry dampness, eliminate phlegm, activate the spleen, soothe liver qi, and harmonize the stomach were applied. The Píng Wèi Săn modification was effective. In the following year, emetics were prescribed following the movement of qi to resolve this problem completely.

Huò Xiāng Zhèng Qì Săn 藿⾹正⽓散Agastache Qi-Correcting Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into powder. Take 9 g with a decoction of shēng jiāng and dà zăo. It may also be prepared as a decoction that includes shēng jiāng and dà zăo.

Formula Indications

Huò Xiāng Zhèng Qì Săn is indicated for the contraction of exogenous wind-cold and internal damage by internal dampness. The symptoms include aversion to co1d with fever, headache, chest and diaphragm distension and depression, abdominal pain, nausea, vomiting, bowel sounds and diarrhea. The tongue has a white, greasy tongue coating. It can also be used to treat conditions that are contracted from the clouds and mists in the mountains, malaria, etc.

Analysis of Fundamental Pattern Pathogenesis This pattern, commonly seen in summer, is caused by externally contracted wind-cold and internal damage by dampness. Wind-cold contraction in the exterior obstructs wei yang and leads to exterior patterns marked by aversion to co1d and fever. Internal damage by dampness in the middle jiao leads to spleen-stomach disharmony and disturbance of ascending and descending marked by vomiting and diarrhea. Qi stagnation due to blockage of dampness is marked by distension and depression of the chest and diaphragm as well as abdominal pain. The proper therapeutic method is to dispel wind-cold externally and remove damp-turbidity internally in combination with methods that rectify qi and harmonize the center. This formula may also be applied to patients who have contracted a similar condition from the clouds and mists in the mountains, malaria, and inability to acclimate.

Formula Actions Releases the exterior and removes dampness, rectifies qi and harmonizes the center.

Formula Analysis

Unique Combination Features Huò Xiāng Zhèng Qì Săn combines methods that dissipate exterior wind-cold and remove dampness and stagnation from the interior. It treats both the exterior and the interior simultaneously. However the removal of dampness in the interior is emphasized over dissipating wind-cold from the

exterior. It also combines the method that fortifies the spleen and removes dampness and that rectifies qi and harmonizes the stomach. This helps repair the clear-ascending and the turbid-descending functions by regulating the spleen and stomach.

Formula Applications 1. Essential pattern differentiation Huò Xiāng Zhèng Qì Săn is the common formula used to treat exterior wind-cold and internal damage by dampness accumulation. This clinical pattern is marked by:

● aversion to wind with fever ● vomiting and diarrhea ● white and greasy tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of dampness stagnation in the spleen and stomach with exterior wind-cold contraction: acute gastroenteritis and common cold in the four seasons. 4. Cautions and contraindications

This formula has a powerful effect to remove dampness and to harmonize the stomach and a mild effect to release the exterior and dissipate cold. After taking it, one should cover up with an extra layer to help release the exterior. It is not applicable for vomiting and diarrhea caused by dampheat.

Associated Formulas Liù Hé Tāng (Six Harmony Decoction, 六和汤) [Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Cut the medicinals into pieces. One doge is 4 qian (12 g). Add 1.5 zhan of water and decoct it with 3 pieces of shēng jiāng and 1 piece of dà zăo until 80% water remain, remove the dregs and take it warm. It can also be prepared as a decoction. [Actions] Dispels summerheat and removes dampness, fortifies the spleen and harmonizes the stomach. [Applicable Patterns]

Damage of the spleen and stomach by dampness, exterior summerheatdamp invasion. Symptoms include: severe vomiting and diarrhea, drowsiness and lassitude, chest and diaphragm distension and depression, and a white, watery tongue coating. Both Liù Hé Tāng and Huò Xiāng Zhèng Qì Săn are used to treat vomiting and diarrhea caused by external wind-cold contraction with internal dampness. Liù Hé Tāng is applicable for damage due to summerheat-dampness, so xiāng rú is heavily used and combined with hòu pò and bái biăn dòu. For dampness consuming the spleen leading to drowsiness and lassitude, rén shēn is used to boost qi and fortify the spleen to improve the transformation and transportation of the spleen. Huò Xiāng Zhèng Qì Săn is applicable for exogenous cold contraction. Therefore, huò xiāng is heavily used and in combination with zĭ sū and bái zhĭ. Chén pí and dà fù pí are used to rectify qi and harmonize the center for the abdominal pain caused by dampness blocking qi movement.

Case Studies 1. Diarrhea due to external pathogen contraction A 24-year-old male had diarrhea followed by aversion to cold, fever, and headache seven hours after contracting a cold. Within those seven hours, he suffered watery diarrhea four times, which was accompanied by abdominal distension, mild pain, and nausea. His tongue coating was thin, white, and slightly greasy. His pulse was floating. Two doses of Huò Xiāng Zhèng Qì Săn (Agastache Qi-Correcting Powder), prepared as a decoction, were prescribed. At the second visit he reported that after one dose, the fever was relieved after sweating, as was the diarrhea, but the abdominal

distension still remained. Following the second dose, the abdominal distension was significantly relieved and the appetite returned. 1 Comments: Diarrhea can be induced by various pathogenic factors, such as contraction of external pathogens, impairment by improper diet and emotional stress, and so on, which are equally essential to the mechanism of diarrhea. In this case, the external wind-cold-damp invasion directly entered and encumbered spleen yang, which led to a disorder of transformation and transportation of the spleen. Consequently, food and water mixed while pouring downward which resulted in diarrhea. Meanwhile, because the exterior pathogens were not able to be dispelled, the patient developed aversion to cold, fever, and a headache. In this case, both exterior and interior patterns are involved. Two doses of Huò Xiāng Zhèng Qì Săn were applied with an effective outcome. 2. Common cold due to summerheat-dampness A female reported having a fever, a headache that felt as though there was something wrapped around her head, nausea, stomach discomfort, and weakness and heaviness of her limbs and joints for over a month. She had taken both medication and Chinese patent medicine that did not help. Huò Xiāng Zhèng Qì Săn was used due to her white greasy tongue coating and her floating pulse. She took three doses and the fever and headache were relieved once she had a significant sweat. Additionally, she would have an occasional cough with sputum. Thus another three doses of Huò Xiāng Zhèng Qì Săn with added shā rén, xìng rén, and chuān bèi mŭ were prescribed. After taking it, her symptoms were alleviated. 2 1 Li Fei. Advanced Collection of Traditional Chinese Medicine: Formulas 中医药学⾼级丛书·⽅ 剂学. Beijing: People’s Medical Publishing House; 2002. 2 Han Ling-di. The Clinical Application of Huò Xiāng Zhèng Qì Săn 藿⾹正⽓散的临床应⽤. Henan Journal of Traditional Chinese Medicine. 1984; (6): 42.

Comments: Summerheat is usually accompanied by dampness. Dampness is associated with the earth element. Generally, summerheat invasion manifests fever and a headache that feels as though there is something wrapping around the head. Furthermore, it definitely gives rise to nausea, diarrhea, and stomach discomfort caused by unsmooth movement and abnormal ascending and descending of the spleen and stomach qi. The therapeutic methods needed are to dispel summerheat and remove dampness and to regulate the ascending and descending of the spleen and stomach qi. These are the indications of Huò Xiāng Zhèng Qì Săn. In this case, symptoms were relieved after taking three doses. The accumulation of dampness produces phlegm, which causes a cough. Therefore, shā rén was added to dispel turbid dampness and phlegm. Additionally, xìng rén and chuān bèi mŭ were added to direct qi downward, eliminate phlegm, and stop coughing. This is an example of treating both the spleen and lung. The effect was quite satisfying.

Section 2 Heat-Clearing and DampnessDispelling Formulas Heat-clearing and dampness-dispelling formulas are applied to patterns of external damp-heat contraction, internal damp-heat accumulation, and damp-heat pouring downward. Commonly seen diseases include dampwarmth, jaundice, cholera, heat strangury, dysentery, diarrhea, wĕi, bì and so on. The formulas are mainly composed of medicinals that clear heat and drain dampness such as yīn chén, huá shí and yì yĭ rén, and medicinals that clear heat and dry dampness such as huáng lián, huáng qín and huáng băi. Common formulas in this category are Yīn Chén Hāo Tāng, Bā Zhèng Săn, Sān Rén Tāng, and Gān Lù Xiāo Dú Dān.

Yīn Chén Hāo Tāng 茵陈蒿汤Virgate Wormwood Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration

Prepare as a decoction.

Formula Indications Yīn Chén Hāo Tāng is indicated for damp-heat jaundice. The symptoms are bright yellow discoloration of the skin, fever, absence of sweating or only sweating on the head, thirst with a desire to drink, nausea, vomiting, slight abdominal distension, scanty dark urine, diarrhea, or constipation. The tongue is red with a greasy yellow coating. The pulse is either deep, rapid or slippery, rapid and powerful.

Analysis of Fundamental Pattern Pathogenesis This formula is a common formula used to treat damp-heat jaundice. Treatise on Cold Damage explains that it is used for yellow skin discoloration due to the interaction of blood stasis and heat. Essentials from the Golden Cabinet explains that it is used for dietary jaundice. Both are caused by heat invasion that mixes with spleen-dampness to cause dampheat accumulation in the middle jiao. Damp-heat always obstructs qi movement. The manifestations include abdominal distension, nausea, vomiting, incomplete defecation, and constipation. Heat is trapped inside due to an absence of sweating and dampness that cannot pour downward due to dysuria. Consequently, damp-heat enters the liver and gallbladder causing an overflow of bile that results in bright yellow skin. Fluid transformation disturbed by damp-heat leads to thirst. A greasy and yellow tongue coating and a deep, rapid pulse indicate an accumulation of damp-heat. The therapeutic principles used to remedy this pattern are to clear heat, drain dampness, and relieve jaundice.

Formula Actions

Clears heat, drains dampness, and relieves jaundice.

Formula Analysis

Unique Combination Features This formula combines methods that remove dampness and discharge heat, unblock the bowels and eliminate blood stasis, and promote urination and defecation to separate and clear damp-heat from the front and the back. However, its primary focus is on clearing and draining.

Formula Applications 1. Essential pattern differentiation Yīn Chén Hāo Tāng is a commonly used formula applicable for jaundice due to damp-heat with equal dampness and heat. This clinical pattern is marked by:

● yellow discoloration of the skin, face, and eyes ● the yellow is bright ● deep and rapid pulse, or slippery, rapid, and powerful pulse

2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of interior damp-heat accumulation: infectious hepatitis with acute jaundice, cholecystitis, gallstone, and jaundice caused by leptospirosis.

Associated Formulas Zhī Zĭ Băi Pí Tāng (Gardenia and Phellodendron Bark Decoction, 栀 ⼦柏⽪汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions]

Clears heat and drains dampness. [Applicable Patterns] Jaundice with more heat than dampness. Symptoms include: feverish sensation, yellow skin discoloration, vexation, thirst, and a yellow coating. Yīn Chén Sì Nì Tāng (Virgate Wormwood Frigid Extremities Decoction, 茵陈四逆汤) [Source] Subtle Meaning of Treatise on Cold Damage (Shāng Hán Wēi Zhĭ Lùn, 伤寒微旨论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Warms the interior and assists yang, drains dampness and removes jaundice. [Applicable Patterns] Yin jaundice. Symptoms include: dark and gloomy skin, aversion to cold on the back, cold extremities, heaviness of the body, mental fatigue, poor appetite, no thirst or prefering hot drinks, loose stool, a pale tongue with a white coating, and a tight, thready or deep, thready and weak pulse. Both Yīn Chén Hāo Tāng and Zhī Zĭ Băi Pí Tāng are applied to yang jaundice caused by dampheat accumulation. Yīn Chén Hāo Tāng is

applicable for excessive damp-heat because it combines yīn chén with zhī zĭ and dà huáng to powerfully clear heat and remove dampness. Zhī Zĭ Băi Pí Tāng is applicable for jaundice caused by more heat than dampness because zhī zĭ is combined with huáng băi to primarily clear heat. Yīn Chén Sì Nì Tāng is applicable for yin jaundice due to cold-damp accumulation because yīn chén is combined with gān jiāng and fù zĭ to warm yang, drain dampness, and relieve jaundice.

Case Studies Coma with jaundice A 15-year-old boy complained of dizziness, sudden loss of appetite, aching and weakness of the four limbs, occasional aversion to cold, absence of fever, dark yellow stool, and brown, scanty urine over the last four days. He reported a gradual yellowing of the skin with itching. There was no bleeding, diarrhea, or stomachache. However, it followed with general yellow skin and sclera discoloration and body temperature of 38˚C. He then fell into lethargy which was accompanied by darkened skin color, unconsciousness, locked jaws, bright yellow skin, mild fever, brown colloidal stool, and dark scanty urine. His pulse was wiry, rapid, and powerful. The diagnosis of acute liver atrophy and hemolytic jaundice caused by damp-heat steaming yangming and taiyin manifesting jaundice was confirmed. Damp-heat attacking the pericardium causes the blockage of the seven orifices and the inability to control mental activities, giving rise to unconsciousness and coma. The therapeutic methods were to remove turbidity and open the orifices using aromatic medicinals and purge heat and dredge the bowels using bitter and cold medicinals. The formulas Yīn Chén Hāo Tāng (Virgate Wormwood Decoction), Zhī Zĭ Băi Pí Tāng (Gardenia and Phellodendron Decoction) and Ān Gōng Niú Huáng Wán (Peaceful

Palace Bovine Bezoar Pill) were applied. Yīn chén 50 g, zhī zĭ 9 g, dà huáng 9 g, huáng băi 6 g, jīn yín huā 15 g, shí chāng pú 4.5 g, mŭ dān pí 4.5 g and gān căo 3 g were decocted first. Two pills of Ān Gōng Niú Huáng Wán (Peaceful Palace Bovine Bezoar Pill) were melted and mixed evenly into the decoction. It was then administrated via a nasal feeding tube. After taking the first dose he had a smooth bowel movement. Afterwards, his mind cleared and the jaundice, as well as, the other accompanying symptoms was alleviated and his body temperature dropped. Therefore, Zhì Băo Dān (Supreme Jewel Elixir) was used instead of Ān Gōng Niú Huáng Wán (Peaceful Palace Bovine Bezoar Pill). Meanwhile, yīn chén 9 g, zhī zĭ 9 g, dà huáng 9 g, huáng băi 6 g, yù jīn 4.5 g, mù tōng 4.5 g, chì fú líng 9 g, zé xiè 6 g, jīn yín huā 12 g, yì yĭ rén 12 g, lián qiào 9 g, huá shí 9 g and gān căo 3 g were used to purge heat and remove the remaining dampness. His symptoms were significantly relieved in one week.1 Comments: In this case, the jaundice was induced by the steaming of damp-heat with heat-toxins invading the pericardium which caused general yellow skin discoloration and unconsciousness. The therapeutic methods for damp-heat and heat-toxins steaming the yangming and disturbing the spirit are to purge heat and dredge the bowels to relieve jaundice by normalizing the gallbladder, open orifices using aromatic medicinals, and awaken the spirit by clearing heat. Therefore, cooling, clearing, and opening medicinals are applied together. Yīn Chén Hāo Tāng and Zhī Zĭ Băi Pí Tāng clear and purge damp-heat in the liver and gallbladder. Ān Gōng Niú Huáng Wán and Zhì Băo Dān clear heat, remove turbidity, and open orifices. An effect is clearly achieved when the medicinals suit the syndrome.

Bā Zhèng Săn 八正散Eight Corrections Powder Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

1 Sun Da-zhi, etc. The Application of Yīn Chén Hāo Tāng Modification for Coma with Jaundice 茵陈蒿汤加减治疗黄疸昏迷. Fujian Journal of Traditional Chinese Medicine. 1984; (4): 3.

Preparation and Administration Grind into powder. Take 6-10 g with a decoction of dēng xīn căo. It can also be prepared as a decoction with dēng xīn căo included.

Formula Indications Bā Zhèng Săn is indicated for damp-heat strangury. The symptoms are frequent urgent urination, odynuria, dribbling urination, dark yellow urine, retention of urine in severe cases, cramps and fullness of abdomen, and a dry

mouth and throat. The coating is yellow and greasy and the pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by damp-heat pouring downward into the bladder. Damp-heat accumulation in the bladder blocks the water passages and leads to frequent and urgent urination, odynuria, dysuria, and retention of urine. Damp-heat steams the urine causing it to become dark and turbid. Qi movement is blocked by damp-heat manifesting cramps and fullness of the abdomen. The distribution of fluid is blocked by damp-heat which leads to a dry mouth and throat. The therapeutic principle is to clear heat, promote urination, and relieve strangury.

Formula Actions Clears heat and subdues fire, promotes urination, and relieves strangury.

Formula Analysis

Continued

Unique Combination Features This formula combines the method to drain fire and dampness with the method to promote urination and unblock the bowels. The objective is to separate damp-heat and guide them downward and out via urination and stool. This formula, recorded in the Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅), was originally applied to treat heat and toxin accumulation in the heart channel of children and adults. Mù tōng, zhī zĭ, dà huáng, chē qián zĭ, and

dēng xīn căo all enter the heart channel and have the therapeutic actions to clear the heart, drain fire, and resolve toxins. Meanwhile, it dredges the small intestine in order to lead dampheat downward. When combined with huá shí, biăn xù and qú mài, it can increase the urinationpromoting and stranguryrelieving functions. It has also been reported that this formula can also be applied to treat dark urination, odynuria, dribbling urinary block, heat strangury, and blood strangury.

Formula Applications 1. Essential pattern differentiation Bā Zhèng Săn is a common formula applied to strangury due to dampheat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of damp-heat pouring downward: cystitis, urethritis, acute prostatitis, urinary stone, pyelonephritis, and postoperative or postpartum urinary retention.

Associated Formulas

Wŭ Lín Săn (Five Strangury Powder, 五淋散) [Source] Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Cools blood and stanches bleeding, promotes urination and relieves strangury. [Applicable Patterns] Blood strangury due to damp-heat. Symptoms include: bean juice-like urination, odynuria, sandy urination, umbilical cramps and abdominal pain. Both Wŭ Lín Săn and Bā Zhèng Săn are applied to patterns of dampheat accumulation in the bladder. Wŭ Lín Săn focuses on clearing heat and cooling the blood by using a heavy dosage of zhī zĭ and chì sháo. Bā Zhèng Săn contains plenty of medicinals to promote urination and relieve strangury. It is effective for heat strangury because it focuses on clearing heat and relieving strangury.

Case Studies 1. Stones in urethral tract

A 46-year-old man was diagnosed with stones in his right kidney by an X-ray radiograph done by the hospital. The stone was as big as his little finger knuckle and had an angular shape. He reported paroxysmal lumbago, fatigue, constipation, hematuria, and a bitter taste. His pulse was moderate, slow, hidden, and excessive. His tongue was red with a white coating. The differentiation of damp-heat accumulation in the bladder was confirmed. Bā Zhèng Săn was applied with additional mù xiāng. The formula included jīn qián căo 15 g, biăn xù 15 g, shēng dì 12 g, qú mài 12 g, huá shí 12 g, hăi jīn shā 12 g, zhī zĭ 9 g, niú xī 9 g, chē qián zĭ 9 g, dà huáng 6 g, mù xiāng 4.5 g, mù tōng 4.5 g, and gān căo 4.5 g. The formula was modified and twenty doses were taken. Finally, a big stone was discharged and all the symptoms disappeared.1 Comments: This case of kidney stone was differentiated as damp-heat accumulation. It is recorded in Beneficial Formulas from the Taiping Imperial Pharmacy that Bā Zhèng Săn is indicated for dysuria, dark urine, dribbling urinary block, heat strangury, and blood strangury. When blood vessels are damaged by stones, blood strangury with hematuria occurs. Effective for damp-heat syndrome, Bā Zhèng Săn can clear heat, remove dampness, and relieve strangury. Additionally, hăi jīn shā and jīn qián căo are used to drain dampness and expel stones. Shēng dì is used to clear heat and cool blood in order to stanch bleeding. Mù xiāng is used to move qi, relieve strangury, and expel stones. Niú xī is used to promote urination and boost the kidney with the action to invigorate blood and unblock collaterals in order to prevent blood stasis. 2. Prostatitis 1 Wu Guang-dai. Application of Bā Zhèng Săn Modifications for Kidney Stone 八正散加减治愈 肾结⽯⼀例. Zhejiang Journal of Traditional Chinese Medicine. 1965; (1):23.

A 50-year-old man with a pale complexion complained of difficult urination with dribbling urine, a burning sensation of urethra, and urgency over the past two days. This morning, he felt an urgency to urinate inhibited by urinary retention, unbearable lower abdominal distending pain, and dry stool. His tongue was red with a thick white coating and his pulse was wiry and slippery. The diagnosis of prostatic hypertrophy complicated by infection was confirmed. According to traditional Chinese medicine, it was caused by damp-heat accumulation in the lower jiao. The therapeutic methods were to clear heat, dissipate the mass, unblock yang, and promote urination. Mù tōng 9 g, chē qián zĭ 9 g, zhī zĭ 9 g, gān căo 9 g, qú mài 9 g, biăn xù 9 g, dà huáng 6 g, huá shí 25 g, ròu guì (brewed) 3 g, huáng qí 15 g, and huáng băi 6 g were prescribed. After taking two doses, he reported that the bladder and bowel movements returned to normal. The urgent urination and dysuria were relieved and his sleeping improved. His tongue was light red with a thick yellow coating on the root of the tongue. His pulse was wiry and thin. Therefore, dà huáng was excluded and bái zhú 12 g was added. After another five doses, his symptoms were all relieved. Finally, medicinals that fortify the spleen and percolate dampness and those that nourish and invigorate blood were applied to cure the condition completely.1 Comments: Prostatitis, as defined in biomedicine, is generally differentiated as strangury in traditional Chinese medicine. The most common pattern of strangury is induced by damp-heat. In this case, Bā Zhèng Săn was used to clear damp-heat accumulation from the lower jiao. Huáng băi is used to strengthen the function of clearing heat and drying dampness. Ròu guì is innovatively combined with huáng qí, to reinforce zheng qi and return fire to its source. Meanwhile, because it is acrid and warm, it might counterbalance the cold, bitter medicinals that could retain water in the body. On the second visit, bái zhú was used to fortify the spleen

and drain dampness for qi and blood deficiency associated with dampness accumulation.

Sān Rén Tāng 三仁汤Three Kernels Decoction Source Text Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications 1 Zhang Xin-liang. Clinical Cases of Bā Zhèng Săn Modification 八正散加减临证举隅. New Medicine. 1975; (5): 264.

Sān Rén Tāng is indicated for the pattern of more dampness than heat in the early stage of damp-warmth and summerheat-warmth with dampness. The symptoms are headache, aversion to cold, heavy body, general pain, fatigue, a light yellow complexion, chest distress without hunger, afternoon

fever, and no thirst. The tongue coating is white and the pulse is wiry, thin, and soggy.

Analysis of Fundamental Pattern Pathogenesis Sān Rén Tāng is a common formula used in the early stages of dampwarmth where the pathogen is in the qi level with more dampness than heat. Generally, there are two causes for this condition. One is external damp-heat contraction. The other is internal dampness and fluid accumulation with external pathogen contraction. When the internal and external pathogens mix together, dampwarmth is the result. When wei yang is obstructed by dampness, there is headache and aversion to cold. Symptoms such as a heavy body, general pain, and fatigue are induced because of the heavy, turbid nature of dampness. When damp-warmth stagnates in the spleen and stomach, there will be a dysfunction of transformation and a blockage of qi movement causing chest distress without hunger. Dampness is a yin pathogen that is active between 3 to 7 pm. Thereby, afternoon fever results from the conflict between zheng qi and pathogenic qi.

Formula Actions Disperses and diffuses qi movement, clears and removes damp-heat.

Formula Analysis

Unique Combination Features This formula combines bland, aromatic, and bitter medicinals to diffuse the upper, free the middle, and drain the lower jiao simultaneously.

Further Clarification This is a confusing pattern that is easily mistreated. Aversion to cold is caused by dampness blocking wei yang which differs from an exterior pattern. Afternoon fever is caused by damp-heat accumulation which differs from the tidal fever due to yin deficiency. Doctor Wu Tang reported three prohibitions in his Systematic Differentiation of Warm Diseases. First, one is prohibited to induce sweating when aversion to cold and headache are seen because sweating damages heart yang. Unconsciousness, deafness, and an inability to open the eyes and mouth may result otherwise. Second, one is

prohibited to apply the purgative method when there is fullness of the middle jiao without hunger because purgatives damage the spleen and stomach. Dampness might invade the lower jiao and lead to through-flux diarrhea as a result. Third, one is prohibited to apply yinnourishing medicinals when an afternoon fever is seen because dampness is a yin pathogen. Otherwise, the dampness and the yin medicinals might mix to cause a lingering and stubborn pathogen. The correct therapeutic methods are to diffuse and disperse qi movement, clear heat, and drain dampness.

Formula Applications 1. Essential pattern differentiation Sān Rén Tāng is applicable to patterns of more dampness than heat in the early stages of dampwarmth. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of dampness more than heat: typhoid, gastroenteritis, pyelonephritis, Brucellosis, glomerulonephritis, and arthritis. 4. Cautions and contraindications

This formula is not applicable for patients with heat more than dampness marked by a yellow greasy tongue coating.

Associated Formulas Huò Pò Xià Líng Tāng (Agastache, Magnolia, Pinellia and Poria Decoction, 藿朴夏苓汤) [Source] Bases of Medicine recorded in A Summary of Externally-contracted Syndromes (Găn Zhèng Jí Yào: Yī Yuán, 感证辑要:医原) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Releases the exterior and removes dampness. [Applicable Patterns] Early stages of damp-warmth. Symptoms include: fever and aversion to cold, fatigue, chest oppression, greasy sensation in the mouth, a thin white coating, and a soggy slow pulse. Huáng Qín Huá Shí Tāng (Scutellaria and Talcum Decoction, 黄芩滑 ⽯汤)

[Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and drains dampness. [Applicable Patterns] Damp-warmth in the middle jiao. Symptoms include: fever and general pain, the fever feels as though it has been released with sweating but then recurs, thirst without drink, a light, yellow and wet tongue coating, and a slow pulse. Huò Pò Xià Líng Tāng, Huáng Qín Huá Shí Tāng and Sān Rén Tāng are three common formulas used to treat damp-warmth. Huò Pò Xià Líng Tāng combines three seeds (xìng rén, yì yĭ rén, and bái dòu kòu), zhū líng and fú líng with huò xiāng and dàn dòu chĭ to promote qi transformation, drain dampness and relieve the exterior. It is used at the early stage of damp-warmth with an obvious exterior pattern. Sān Rén Tāng combines xìng rén, yì yĭ rén and bái dòu kòu with huá shí and zhú yè to promote qi transformation and drain dampness, dispel

summerheat, and clear heat. It is used at the early stage of damp-warmth with more dampness than heat. Huáng Qín Huá Shí Tāng combines huáng qín with huá shí, zhū líng and fú líng to clear heat and drain dampness. It is used for damp-warmth in the middle jiao with equal dampness and heat.

Case Studies 1. Summerheat The day before yesterday, a patient with a headache due to summerheat was treated by clearing the gallbladder because the left guān pulse was floating and wiry, indicating a disorder of the shaoyang. The left guān pulse became less floating and wiry today. It became moderate and was accompanied with a white, thick and glossy tongue coating and chest oppression. These are signs of dampness accumulation associated with summerheat. The therapeutic methods used were to diffuse dampness in the qi level in the upper jiao first. Therefore, yì yĭ rén, huá shí, huò xiāng gĕng, xìng rén, bàn xià, yù jīn, xuán fù huā, chén pí, tōng căo, fú líng pí, and bái dòu kòu were prescribed.1 1 Qin Bowei. Essential Case Records of Famous Physicians of the Qing Dynasty-Essential Case Records of Wu Ju-tong 清代名医医案精华·吴鞠通医案精华. Shanghai: Shanghai Medical Publishing House; 1958.

Comments: This was a case of a shaoyang headache following summerheat contraction. The method to clear gallbladder heat was applied by doctor Wu. Dampness remained after the heat was cleared and a typical pattern of more dampness than heat was the result. Although the name of the treatment infers diffusion of the upper jiao, it actually had the actions to open the upper, free the middle and drain the lower jiao by using the three seeds. Additionally, huò xiāng gĕng and bái dòu kòu were combined to

resolve dampness and refresh the spleen with acridity. Chén pí was used to move qi and dry dampness. Xuán fù huā facilitates qi movement and directs qi downward to help remove dampness by promoting smooth qi movement. Bàn xià dries dampness and yù jīn relieves constraint. Huá shí, tōng căo, and fú líng pí percolate dampness. The formula combines the methods to resolve, dry, and drain dampness. However, its focus is on percolating dampness. Furthermore, it opens the sluice gate because xìng rén regulates the dispersion and descent of lung qi to direct dampness downward. This is associated with the therapeutic method of promoting urination by diffusing lung qi. 2. Damp-warmth On the tenth (according to the lunar calendar), a patient came with a wiry and thready pulse on all three positions of both hands. His left pulse was rapid and powerful when pressed. He also had a slightly yellowish complexion and icteric sclera. He said that he had an afternoon fever since the spring equinox. He was weak with an absence of thirst following an episode of severe diarrhea. His stool was unformed and urine was clear before noon, yet his urine was dark and turbid after noon. The therapeutic methods were to clear heat within dampness using cold, bitter, and acrid medicinals. Huá shí 6 qian, yīn chén 4 qian, cāng zhú tàn 3 qian, fú líng pí 5 qian, xìng rén 3 qian, cán shā 3 qian, yì yĭ rén 5 qian, huáng qín 2 qian, tōng căo 1.5 qian, hăi jīn shā 4 qian, and huáng lián 1 qian were prescribed. Three bowls of the decoction were taken three times daily. On the thirteen, cāng zhú tàn was removed, shí gāo was added, and huáng lián and huáng qín were increased.1 Comments: This is a case study about a pattern of damp-heat. The application of cold, bitter, and acrid medicinals by Wu Ju-tong is actually a

modification of the combination of Sān Rén Tāng (Three Kernels Decoction) and Huáng Qín Huá Shí Tāng (Scutellaria and Talcum Decoction). As dampness decreased and heat increased, cāng zhú, a warm medicinal, was removed and shí gāo, huáng lián, and huáng qín (cold medicinals) were added to clear heat. It is recorded in the Systematic Differentiation of Warm Diseases·Volume 2 (Wēn Bìng Tiáo Biàn-Juàn Èr, 温病条辨·卷⼆) that in any pattern of damp-heat solely clearing heat may leave dampness behind while solely dispelling dampness may induce intense heat. Therefore, the appropriate methods are to diffuse qi and promote urination. This is because dampness may be resolved as qi transformation is improved and heat may be cleared when urination and bowl movement is smooth. It can be seen that methods to move qi and promote urination are important in any pattern of damp-heat.

Gān Lù Xiāo Dú Dān ⽢露消毒丹Sweet Dew Toxin-Removing Elixir Source Text The Secret Transmission of Effective Medicine (Yī Xiào Mì Chuán, 医 效秘传)

Formula Ingredients

1 Wu Tang. Wu Ju-tong’s Case Records 吴鞠通医案. Beijing: People’s Medical Publishing House; 1960.

Preparation and Administration Grind the medicinals into powder and take 6-9 g as a single dose. It can also be prepared into pills. Take 9-12 g of the pills for each dose. In addition, it can also be prepared as a decoction.

Formula Indications Gān Lù Xiāo Dú Dān is indicated for damp-warmth and seasonal epidemic. It is a pattern with equal dampness and heat pathogens in the qi level. The symptoms are fever and fatigue, chest distress and abdominal distension, aching pain of limbs, throat pain, yellow skin and eyes, maxillofacial swelling, thirst, scanty dark urine, diarrhea, and turbid strangury. The tongue coating may be either white, thick and greasy or yellow and dry. The pulse is either soggy and rapid or slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis This formula is applied to patterns that have equal dampness and heat. Fever, aching pain of the limbs and fatigue are caused by heat steaming dampness. Chest distress and abdominal distension are caused by dampness accumulation in the middle jiao. Yellow skin and eyes are caused by dampheat steaming in the liver and gallbladder. Thirst, throat pain, and maxillofacial swelling are caused by heat attacking the upper jiao. Scanty dark urine, diarrhea, and turbid strangury are caused by damp-heat pouring downward. A tongue with thick, white and greasy or dry, yellow coating is a sign of damp-heat stagnation in the qi level. The therapeutic methods are to drain dampness and remove turbidity and to clear heat and resolve toxins.

Formula Actions Drains dampness and removes turbidity, clears heat and resolves toxins.

Formula Analysis

Continued

Unique Combination Features In this formula, there are three therapeutic methods combined. They are to clear the upper, free the middle and drain the lower jiao by using medicinals that clear heat, drain dampness, and resolve toxins.

Formula Applications 1. Essential pattern differentiation Gān Lù Xiāo Dú Dān is a common formula used in the summer for damp-warmth and seasonal epidemic with equal amounts of dampness and heat. Doctor Wang Shi-xiong named it as the principal formula for treating damp-warmth. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of equal dampness and heat: typhoid, acute gastroenteritis, infectious hepatitis with jaundice, leptospirosis, and cholecystitis. 4. Cautions and contraindications This formula is not applicable for damp-heat invading the ying level, marked by delirious speech and crimson tongue.

Comparison & Contrast Sān Rén Tāng vs. Gān Lù Xiāo Dú Dān

Continued

Case Studies 1. Typhoid A 35-year-old man had a fever, the charting of his temperature increasing in a trapezoidal fashion, accompanied with abdominal distension and poor appetite for the past ten days. The Widal test revealed typhoid. He reported a persistent high temperature of 39.4°C, dizziness with distending eyes, tiredness, aching pain of the four limbs, thirst with a desire to drink, chest oppression, poor appetite, scanty dark urine, and no expression. The tip of his tongue and margins were red with a thick greasy tongue coating. His pulse was soggy and moderate. His was a pattern of stagnant dampheat with unsmooth qi movement. The therapeutic methods were to remove dampness and clear heat and to ventilate qi to drive away pathogens. The prescription included huá shí 18 g, huò xiāng 10 g, lián qiào 10 g, bò he 6 g, bái dòu kòu 6g, yīn chén 20 g, huáng qín 10 g, shí chāng pú 10 g and mù tōng 10 g. After taking four doses, the high fever was significantly relieved and the appetite was normal. Then, after another four doses were prescribed with huáng qín

removed, all of the symptoms were relieved. Half a month later the condition was cured.1 Comments: Typhoid belongs to damp-warmth disease in traditional Chinese medicine. It is mostly caused by a damp-heat invasion. Dampness and heat dormant in the body leads to the failure of ascension or descending of qi, in turn, causing a high fever. Therefore, the therapeutic methods are to clear heat, remove dampness, and ventilate qi to drive away pathogens. However, chuān bèi mŭ and shè gān are excluded because the patient did not report mumps nor throat swelling. After the fever cleared, huáng qín was removed to prevent over consumption of cold medicinals that keeps dampness in the body. It is said by Wang Shi-xiong that Gān Lù Xiāo Dú Dān is the first choice for treating damp-warmth disease caused by plagues. 2. Persistent fever 1 Zhang Zong-ru. Cases of Application of Gān Lù Xiāo Dú Dān ⽢露消毒丹应⽤举隅. Jilin Journal of Traditional Chinese Medicine. 1990; (5): 30.

A 16-year-old man reported a persistent idiopathic high fever. His high temperature of 39°C lasted for over ten days with a headache. No medicines offered effect. His temperature gradually reached 39.2°C. It was worse in the afternoon, complicated by mental fatigue, fullness and oppression in chest and abdomen, poor appetite, sticky and dry sensation in the mouth, nausea, sweating, vexation, and difficult defecation. The therapeutic methods were to clear heat, remove dampness and regulate qi activity. The prescription included huá shí 45 g, bái dòu kòu 9 g, huò xiāng 12 g, bò he 9 g, lián qiào 30 g, jīn yín huā 30 g, yīn chén 30 g, shí chāng pú 15 g, huáng qín 15 g, zhĭ shí 15 g, dà huáng 15 g and yì yĭ rén 30 g. After one dose, the high fever was relieved. After three doses, the fever was gone. After another five doses were taken, all the symptoms disappeared.1

Comments: The symptoms in this case were caused by the co-existence of dampness and heat marked by fever that is worse in the afternoon. Dampness pertains to yin and is heavy, turbid, and sticky in nature. When it is mixed with heat, the spleen becomes affected. It causes abnormal transformation and transportation which leads to distention and fullness of the epigastrium and abdomen, poor appetite, nausea, and a red tongue with a greasy coating. Gān Lù Xiāo Dú Dān is used to clear heat and resolve toxins and to drain dampness and remove turbidity. Furthermore, because persistent fever is typically caused by heat-toxin, jīn yín huā, lián qiào, and bò he were combined to clear heat and resolve toxins. Zhĭ shí and dà huáng were combined to purge heat. Following the guidance of the correct principle, a flexible and effective prescription was made.

Lián Pò Yĭn 连朴饮Coptis and Officinal Magnolia Bark Beverage Source Text Treatise on Sudden Turmoil (Huò Luàn Lùn, 霍乱论)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications 1 Liu Mei-yu, Zhao Yue-lan. New Application of Gān Lù Xiāo Dú Dān ⽢露消毒丹新⽤. Hebei Journal of Traditional Chinese Medicine. 1995; (5): 3.

Lián Pò Yĭn is indicated for damp-heat cholera. The symptoms are vomiting, diarrhea, chest and epigastric pĭ and oppression, vexation and agitation, and scanty dark urine. The tongue coating is yellow and greasy, and the pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis Lián Pò Yĭn is the main formula for damp-heat induced cholera marked by vomiting. It is caused by damp-heat stagnation that leads to a conflict between the clear and the turbid, with equal dampness and heat. Damp-heat stagnation in the middle jiao causes disorder of ascension and descending of the spleen and stomach. When turbid qi fails to descend, there is vomiting. When clear fluids fail to ascend, there is diarrhea. Chest and epigastric pĭ and oppression are caused by the blockage of qi movement. Scanty dark urine is caused by damp-heat pouring downward. The yellow greasy tongue coating and the slippery pulse are evidence of damp-heat accumulation. The therapeutic methods are to clear heat and dispel dampness, rectify the qi, and harmonize the center.

Formula Actions Clears heat and dispels dampness, rectifies qi, and harmonizes the center.

Formula Analysis

Unique Combination Features This formula combines medicinals that clear heat and dispel dampness with those that rectify qi and harmonize the center. Damp-heat is removed when the clear ascends and the turbid descends. Consequently, the spleen and stomach will be harmonized and the vomiting and diarrhea relieved.

Formula Applications 1. Essential pattern differentiation Lián Pò Yĭn is a common formula used to treat damp-heat cholera with equal amounts of dampness and heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of equal dampness and heat: acute gastroenteritis, typhoid, and paratyphoid.

Comparison & Contrast Huò Xiāng Zhèng Qì Săn vs. Lián Pò Yĭn

Case Studies

Damp-warmth (equal dampness and heat) A 43-year-old lady reported headache, aversion to cold, fever, cough, itching throat, thirst with a desire for drink, pĭ and oppression of the abdomen and chest, cold legs and difficult defecation. Her tongue coating was yellow, greasy and glossy and her pulse was soggy and slippery yet wiry, slippery, and rapid when pressed. She had suffered these symptoms for over four weeks due to excessive summerheat and dampness accumulation. The therapeutic methods were to ventilate summerheat and dissipate dampness with aromatic medicinals. Furthermore, disease transmission may be considered a condition of pathogenic excess where the deficiency of zheng qi gave rise to reverse transmission. Thus, dàn dòu chĭ 12 g, jiāo zhī zĭ 4.5 g, qián hú 3 g, bái jí lí 10 g, fresh pí pá yè 10 g, jīn fèi căo 4.5 g, bàn xià (processed) 10g, gān căo 4.5 g, huáng lián 2 g, yì yĭ rén (scorchfried) 10 g, bái dòu kòu 4.5 g, chén pí 6 g and chì fú líng 10 g were prescribed. After two doses, the chills and fever were relieved, as were the headache associated with dizziness and the cough with frothy sputum. Her legs became warm, she was less thirsty, and she had a throbbing sensation in her abdomen with tenderness. Her tongue was crimson with a glossy, white coating. Her pulse was soggy and soft, yet when pressed, it became wiry, slippery and rapid. Several doses of the modified formula were prescribed until the disease was cured.1 Comments: In general there are two reasons that might lead to a dampwarmth disease lasting over four weeks. One is the disease was mistreated and the other is the patient has a weak constitution. The priority of the treatment is to remove dampness constraint. The therapeutic methods are to diffuse yang qi, resolve dampness, relieve stagnation, ventilate the lung, and dredge the sanjiao. They might be applied initially, even when dampness and heat have accumulated equally. Once the sanjiao is unblocked, qi

movement becomes smooth again allowing dampness to be removed and heat cleared. If the treatment of clearing heat is taken as the priority, recovery of the disease will certainly be delayed because accumulated dampness will remain. In this prescription qián hú, pí pá yè, jīn fèi căo, and bàn xià are combined to dry dampness, moisten the lung, and dissolve phlegm in order to relieve the cough and itching throat. Yì yĭ rén and bái dòu kòu enter the middle jiao and lower jiao respectively in order to fortify the spleen and dispel dampness. Chén pí is used to move qi and help dispel dampness because dampness dissolves with increased qi movement. Chì fú líng is used to fortify the spleen and percolate dampness to address the origin of the dampness production.

Dāng Guī Niān Tòng Tāng 当归拈痛汤Chinese Angelica Pain-Alleviating Decoction a.k.a Niān Tòng Tāng (Pain-Alleviating Decoction, 拈痛汤) Source Text Origins of Medicine (Yī Xué Qĭ Yuán, 医学启源)

Formula Ingredients

1 Zhao Shao-qin. Discussion on Warm Diseases 温病纵横. Beijing: People’s Medical Publishing House; 1982.

Preparation and Administration

Prepare as a decoction.

Formula Indications Dāng Guī Niān Tòng Tāng is indicated for patterns that arise due to a conflict between dampness and heat with concurrent external wind contraction. The symptoms are aching pain of limbs and joints, heavy sensation of the shoulder and back, swelling and pain of the feet, sores on the feet and knees. The tongue coating is white and greasy mixed with yellow and the pulse is wiry and rapid.

Analysis of Fundamental Pattern Pathogenesis Dāng Guī Niān Tòng Tāng is applied to the complex pattern of winddamp-heat with dominant dampness due to either internal damp-heat accumulation with external wind contraction or winddampness that has transformed into heat. Pathogenic wind, dampness, and heat accumulation in the channels block qi and blood movement. This condition manifests aching pain of the limbs and joints. The heavy sensation of shoulders and back is caused by the dominant dampness. Damp-heat pouring downward gives rise to swelling and pain in the feet, as well as sores on the feet and knees. Mixed white and yellow greasy coating and the wiry and rapid pulse are signs of damp-heat. The therapeutic methods are to eliminate dampness as priority and clear heat and scatter wind to relieve pain secondarily.

Formula Actions Drains dampness and clears heat, scatters wind and relieves pain.

Formula Analysis

Continued

Unique Combination Features This formula combines medicinals that disperse and scatter winddampness with ones that remove dampness and clear heat in order to treat both the exterior and interior. It dries and drains dampness while supplementing qi and nourishing blood to address both pathogenic qi and zheng qi.

Formula Applications 1. Essential pattern differentiation

Dāng Guī Niān Tòng Tāng is the common formula for wind-damp-heat bì and jiăo qì (脚⽓)1 due to damp-heat with excessive dampness. This clinical pattern is marked by:

● pain, heaviness, and swelling of the limbs and joints ● mixed white and yellow greasy tongue coating ● rapid pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of damp-heat accumulation with exterior pattern: rheumatic arthritis and rheumatoid arthritis.

Associated Formulas Xuān Bì Tāng (Painful Obstruction Resolving Decoction, 宣痹汤) [Source] Systematic Differentiation of Warm Diseases (Wēn Bìng Tiáo Biàn, 温 病条辨) [Ingredients]

1 As a certain disease in TCM, refers to ulcerarion, skin rashes with exudate, etc. on feet, caused by dampness pouring downward.

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and eliminates dampness, unblocks collaterals and relieves pain. [Applicable Patterns] Bì syndrome due to damp-heat accumulation in the channels and collaterals. Symptoms include: chills and fever, aching pain of the joints, a withered-yellow complexion, and a grey tongue without luster. Both Dāng Guī Niān Tòng Tāng and Xuān Bì Tāng are applied to damp-heat bì syndrome. Dāng Guī Niān Tòng Tāng is effective for winddamp contraction with exterior wind-cold because it drains dampness, clears heat, and scatters wind. Xuān Bì Tāng is effective for bì syndrome due to dampheat accumulation in the channels and collaterals because it removes dampness, clears heat, dredges the collaterals, and relieves pain.

Case Studies General pain Case #1: Jiang Ying-su once treated the eldest son of Mr. Cheng Jungao. He was 18 years old and reported general body pain, swelling of the feet and knees, a feverish sensation of the whole body, and a red face. His condition was caused by wind conflicting with dampness. Two to three doses of Dāng Guī Niān Tòng Tāng were applied. The symptoms were relieved as the body temperature decreased.1

Case #2: Gong Zi-cai once treated Zhang Tai-pu who reported general stabbing pain of the body for years, only when there was cloudy weather. His left pulse was slightly rapid and the right pulse was surging and rapid. It was differentiated as blood deficiency with damp-heat. Several doses of Dāng Guī Niān Tòng Tāng combined with added shēng dì, bái sháo, and huáng băi with the rén shēn removed were applied. The disease was cured.2 Comments: The first case has general pain, swelling of the feet and knees, feverish sensation of the whole body, and a red face caused by wind conflicting with dampness. Dāng Guī Niān Tòng Tāng is used to dispel wind and dampness. The second case has general pain caused by blood deficiency with damp-heat. Dāng Guī Niān Tòng Tāng is effective for draining dampness and clearing heat and for dispelling wind and relieving pain. Meanwhile, shēng dì and bái sháo were combined to nourish blood and reinforce zheng qi. Thereby, a disease that persisted for years was cured.

Èr Miào Săn ⼆妙散Wonderfully Effective Two Powder Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

1 Jiang Quan. Classified Case Records of Famous Physicians 宣统元年.名医类案. Shanghai: Shanghai Book Bureau, first year of Xuan Tong. 2 Wu Zhi-xiu. Supplement to ’Classified Case Records of Famous Physicians’ 续名医类案. Shanghai: Zhu Yi Tang Scripture of Shanghai; 1886.

Preparation and Administration Grind the medicinals into powder and divide them equally, mix with shēng jiāng and take 3-5 g. It can also be prepared into pills, or as a decoction.

Formula Indications Èr Miào Săn is indicated for damp-heat pouring downward. The symptoms are pain of the sinews and bone, flaccidity of feet, swelling and pain of feet and knee, vaginal discharge, eczema, sores on the lower body, and scanty dark urine. The tongue coating is yellow and greasy.

Analysis of Fundamental Pattern Pathogenesis

Èr Miào Săn is a basic formula applicable to the pattern of damp-heat pouring downward. Damp-heat pouring downward into lower limbs causes a slackening of the sinews which resulting in flaccidity and weakness of the feet. This disease process is referred to as wĕi syndrome. Damp-heat blockage in the tendons and channels causes pain of the sinews and bone, redness and swelling of the feet and knees, or may even develop into jiăo qì. Damp-heat pouring downward into the dai mai and female external genitalia causes turbid vaginal discharge with an unpleasant odor and sores in the lower body. Scanty dark urine and a yellow and greasy tongue coating are also signs of damp-heat. The therapeutic methods are to clear heat and dry dampness.

Formula Actions Clears heat and dries dampness.

Formula Analysis

Unique Combination Features

This formula combines bitter and cold medicinals to clear heat and dry dampness with bitter and warm medicinals to fortify the spleen and dry dampness. It coordinates yin and yang, balances cold and heat, and regulates the root and branch. When heat is cleared and dampness is eliminated, symptoms are relieved.

Formula Applications 1. Essential pattern differentiation Èr Miào Săn is a basic formula applicable for wĕi, bì, jiăo qì, leukorrhagia, and sores due to damp-heat pouring downward. The damp heat is excessive with equal amounts of dampness and heat. It has powerful actions to clear heat and dry dampness. This clinical pattern is marked by:

● swelling and pain of the feet and knees ● scanty dark urine ● yellow greasy tongue coating 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of damp-heat pouring downward: rheumatic arthritis, scrotum eczema, and vaginitis.

Associated Formulas Sān Miào Wán (Wonderfully Effective Three Pill, 三妙丸) [Source] Transmission of Medicine (Yī Xué Zhèng Zhuàn, 医学正传) [Ingredients]

[Preparation and Administration] Grind the medicinals into fine powder and prepare it into pills, take 1015 g with ginger juice and salt water. [Actions] Clears heat and dries dampness. [Applicable Patterns] Wĕi and bì due to damp-heat pouring downward. Symptoms include: numbness, swelling, and pain of the feet, fire-burning sensation in the feet, and flaccidity of the feet. Sì Miào Wán (Wonderfully Effective Four Pill, 四妙丸) [Source] Convenient Reader on Established Formulas (Chéng Fāng Biàn Dú, 成 ⽅便读) [Ingredients]

[Preparation and Administration] Grind the medicinals into fine powder and prepare it into pills, take 6-9 g with warm water. [Actions] Clears heat and drains dampness, relaxes the sinews and strengthens the bones. [Applicable Patterns] Wĕi syndrome due to damp-heat. Symptoms include: numbness of the feet, flaccidity of the feet, swelling and pain of the feet. Sān Miào Săn is composed by Èr Miào Săn and niú xī. Niú xī can supplement the liver and kidney, strengthen the sinews and bones, and guide other medicinals to descend. Therefore, Sān Miào Wán is particularly applicable to numbness and flaccidity of the feet due to damp-heat in lower jiao. Sì Miào Săn is composed by Sān Miào Săn plus yì yĭ rén. Yì yĭ rén can percolate dampness, relax the sinews and relieve spasms. Therefore, Sì Miào Wán is applied to wĕi syndrome due to damp-heat pouring downward.

Case Studies Fixed bì Three months ago a 15-year-old boy suddenly had a fever, pain and numbness of the lower limbs with edema and red spots, and he felt flustered. His ESR measured 71mm/h and was diagnosed with “rheumatic fever and erythema nodosum”. Recently he suffered frequent recurrence of knee pain, heaviness in the lower limbs, difficulty engaging in activities, dry throat,

thirst without a desire to drink, normal defecation and urination, and scanty yellow urine. Examination of the heart and lungs showed nothing remarkable and the joints of limbs were not obviously swollen. The lower limbs had mild pitting-edema with scattered purpura in front of the shank. His tongue was red with a yellow, greasy coating and his pulse was deep and wiry on the left and slippery and slightly rapid on the right. Laboratory examination showed nothing remarkable in the blood or urine and his ESR was: 58mm/h, 90mm/next h. His condition was differentiated as damp-heat pouring downward with stagnant blood. The treatment should be to clear heat and dispel dampness, invigorate and cool blood, and unblock the collaterals. Modified Sì Miào Wán was prescribed. Ingredients included cāng zhú 10 g, huáng băi 10 g, niú xī 15 g, yì yĭ rén 20 g, rĕn dōng téng 30 g, wēi líng xiān 15 g, sāng zhī 20 g, qín jiāo 10 g, dāng guī 12 g, shēng dì 15 g, mŭ dān pí 10 g and zĭ căo 10 g. After taking ten doses, the pain and numbness in the lower limb was greatly relieved. The edema decreased a little along with the dark purpura. He also had palpitations. His tongue was red with a white and slightly greasy coating. His pulse was deep, thready, and slightly rapid. Although the symptoms improved, lóng chĭ 15 g and lián zĭ xīn 6 g were added to the original prescription in order to clear heart heat and calm the mind for a total of four doses. By the third visit, the condition stabilized and the purpura, pain, numbness, and edema disappeared. Also there was no more heavy sensation of the two lower limbs. However, he still felt palpitations and restlessness at night. And his tongue and pulse characteristics were still the same. So, suān zăo rén (dry-fried) 15 g was added to the original prescription. Fourth visit: He had been asked to take ten doses of the above prescription. However, during the treatment course, the patient caught a cold

and felt some pain in the lower limbs. So some medicinals were added to dispel the pathogenic factors from exterior for two to three days. With that modification, the pain of lower limbs disappeared, as well as the palpitations and insomnia. The symptoms did not recur, laboratory blood tests confirmed that the blood and urine were normal, and the ESR measured 11mm/h. Another seven doses of the former prescription were required to consolidate its effect.1 1 Dong Jian-hua. Sential Case Records of Famous Physicians of Modern China 中国现代名中医 医案精华. Beijing: Beijing Publishing House; 1990.

Comments: The pain in the lower limbs, edema, numbness, heavy sensation, and difficulty to engage in activities were all caused by dampness stagnation. The initial fever, bitter taste in the mouth, dry throat, thirst without a desire to drink, red tongue, yellow greasy coating, wiry, slippery, and slightly rapid pulse were all signs of heat accumulation and damp-heat flowing downward. Dampness stagnates in the channels and collaterals and blocks the movement of qi and blood. Blood stagnation develops into cutaneous purpura. Since damp-heat pouring downward is the main cause of the disease, adding heat-clearing and blood-activating medicinals to Sì Miào Wán brings a satisfactory effect. On the second visit, lóng chĭ was added to calm the mind and lián zĭ xīn to pacify the heart. This was done in light of the palpitations, red tongue, and rapid pulse. On the third visit, suān zăo rén was added in to nourish the heart and calm the mind to help sleep because of the insomnia.

Section 3 Urination-Promoting and Dampness-Percolating Formulas Urination-promoting and dampness-percolating formulas are used to treat edema and diarrhea caused by an accumulation of water-dampness. Common medicinals used to promote urination with their sweet flavor and bland natures include fú líng, zé xiè, and zhū líng. Common formulas in this category are Wŭ Líng Săn and Zhū Líng Tāng.

Wŭ Líng Săn 五苓散Five Substances Powder with Poria Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Grind the ingredients into powder and take 6-10 g. It can also be prepared as a decoction. After ingestion, drink hot water to induce a light

sweat.

Formula Indications Wŭ Líng Săn is indicated for water amassment syndrome due to dysfunction of bladder qi transformation. The symptoms are dysuria, headache with mild fever, thirst and desire to drink, vomiting as soon as drinking, throbbing below the navel, spitting, dizziness, shortness of breath, cough, edema, and diarrhea. The tongue coating is white and the pulse is either floating or floating and rapid.

Analysis of Fundamental Pattern Pathogenesis While the indications are various, this pattern has the same pathogenesis of excessive internal water-dampness and dysfunction of bladder qi transformation. In the Treatise on Cold Damage, this formula is used for water amassment syndrome. It is caused by external pathogens in the taiyang entering the corresponding fu-organ along the channels that leads to a disease involving both the taiyang channel and its fu-organ. External pathogenic contraction in the taiyang gives rise to headache and mild fever. The failure of bladder qi transformation leads to dysuria. Retention of water blocks yang qi and results in qi failing to diffuse fluids. This in turn leads to the failure of fluid ascending into the mouth causing thirst with a desire to drink. Water stagnation in the lower jiao hinders the ability for fluids that are drunk to distribute. This causes water counterflow marked by vomiting as soon as drinking. It is also called water-up rushing pattern. Excessive waterdampness spills over the skin manifesting edema. When water-dampness descends into the large intestine, diarrhea is the result. When waterdampness accumulates in the stomach and intestine, a disharmony between the ascension and descending will result. In this case, a conflict between the

clear and turbid will manifest vomiting and diarrhea. When water accumulates in the lower jiao, water and zheng qi conflict with each other and cause throbbing below the navel. When water up rushes and invades the upper jiao, the lung qi is blocked. This causes shortness of breath and coughing. The therapeutic methods are to promote urination and percolate dampness; however, methods to warm yang and promote qi transformation are also used.

Formula Actions Promotes urination and percolates dampness, warms yang and promotes qi transformation.

Formula Analysis

Unique Combination Features

In this formula, the methods to promote urination and percolate dampness are combined with the methods to warm yang and promote qi transformation. Additionally, its flexible administration adapts well to the syndrome.

Formula Applications 1. Essential pattern differentiation Wŭ Líng Săn is a common formula used to promote urination and qi transformation. This clinical pattern is marked by:

● dysuria ● white tongue coating ● floating or slow pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of retention of water and dampness: edema in acute or chronic nephritis, ascites in liver cirrhosis, cardiac edema, acute enteritis, urinary retention, and hydrocephalus.

Associated Formulas

Sì Líng Săn (Four Substances Powder with Poria, 四苓散) [Source] Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法) [Ingredients] Wŭ Líng Săn minus guì zhī. [Preparation and Administration] Grind the medicinals into a fine powder. One dose is 4 qian (12 g). Prepare it as a decoction. [Actions] Fortifies the spleen and percolates dampness. [Applicable Patterns] Retention of water-dampness due to deficiency of the spleen and stomach. Symptoms include: scanty dark urine and loose stool. Wèi Líng Tāng (Stomach-Calming Poria Decoction, 胃苓汤) [Source] Effective Formulas from Generations of Physicians (Shì Yī Dé Xiào Fāng, 世医得效⽅) [Ingredients]

[Preparation and Administration] Mix these medicinals and decoct them with zĭ sū and wū méi .

[Actions] Dispels dampness and harmonizes the stomach, moves qi, and promotes urination. [Applicable Patterns] Cold damage of the spleen and stomach in-between summer and autumn leading to the failure to separate the clear and turbid. Symptoms include: watery diarrhea, edema, abdominal distension, and dysuria. Yīn Chén Wŭ Líng Săn (Five Substances Powder with Poria Plus Virgate Wormwood, 茵陈五苓散) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Drains dampness and relieves jaundice. [Applicable Patterns] Damp-heat jaundice with dysuria and more dampness than heat.

Case Studies 1. Dysuria

The father of Wang Shang-xin was over 50 years old. In June, he reported sudden urinary retention. Over the past five days, he was treated by many doctors. Then finally, he was treated by Cheng Ren-fu. His pulse was deep and thready in all six divisions. His was a pattern of interior hidden yin during the hot summer. It was caused by drinking too many cold drinks and taking cold medicinals which led to the failure of qi transformation. Wŭ Líng Săn with double ròu guì was prescribed and cōng bái was decocted for bathing. After one dose the urination was normal.1 Comments: Summer is a season with excess environmental dampness. Drinking too many cold drinks or taking too many cold medicinals might damage the yang qi and lead to the failure of qi and body fluid transformation. As a consequence, binding water and dampness gives rise to dysuria. Wŭ Líng Săn has the actions to drain water-dampness and promote the transformation of yang qi. With doubled ròu guì and cōng bái for bathing, the movement of yang qi became smooth and qi transformation was improved. One dose could solve this problem. 2. Diarrhea Jiang Ying-shu once treated a 17-year-old male servant in Yu’s family. Early in May, he suffered diarrhea and by June he became emaciated. He had not eaten for five days and was dying. His pulse was deep, thin, soggy, soft and moderate. His master was told that it was caused by spleen damage due to dampness. Wŭ Líng Săn with rén shēn 3 qian and bái zhú 3 qian was applied. After taking the formula, the patient asked for porridge. After taking another three doses he recovered.1 Comments: Diarrhea in this case is due to dampness damaging the spleen. The patient became emaciated due to long-term diarrhea. Dysfunction of the spleen leads to loss of appetite. However, the soggy,

weak, thready, and moderate pulse indicate spleen deficiency with excessive dampness. Therefore, Wŭ Líng Săn was applied to percolate dampness and fortify the spleen. Rén shēn and bái zhú were added to modify the formula’s action, promote urination, boost qi, fortify the spleen, and dispel dampness. It is a formula modification designed to embody the germination of spring, “Chūn Zé”(春泽), in order to improve the transformation and transportation of the spleen by removing dampness. 3. Polyuria (diabetes insipidus) A 7-year-old boy drank a lot and urinated a lot. He was diagnosed as having polyuria with a USG (urine specific gravity) of 1.007 in a local hospital. He was treated in vain, so he came to Jinan. He had a normal pulse and complexion. But his tongue was pale with a white and glossy coating much like a thin, uneven film of paste. So it was inferred that his persistent thirst for drinks was caused by the failure of body fluid distribution due to the stagnation of fluids in the body. Wŭ Líng Săn composed of bái zhú 12 g, fú líng 9 g, zé xiè 6 g, guì zhī 6 g, and zhū líng 6 g was prescribed as a decoction. After taking two doses, his parent reported that he was getting better. He recovered with two more doses.2 1 Jiang Quan. Classified Case Records of Famous Physicians 名医类案. Shanghai: Shanghai Book Bureau, first year of Xuan Tong. 2 Li Shao. Clarifying Doubts of Cold Damage 伤寒解惑论. Jinan: Shandong Science & Technology Press; 1984.

Comments: Children often have tender yang lacking the complete function of yang qi. Deficient qi transformation cannot distribute fluid up to the upper jiao leading to polydipsia. Deficient steaming function of yang qi leads to polyuria. Therefore, Wŭ Líng Săn was used to warm yang and promote urination. Yang qi raised the body fluid so the thirst was quenched. In this prescription of Wŭ Líng Săn, bái zhú was heavily used instead of zé

xiè, and bái zhú was used together with guì zhī because the purpose was to both promote the urination and tonify zheng qi as it relates to child’s immature yang qi. From this case, we can see the great ingenuity in the modification of the prescription.

Zhū Líng Tāng 猪苓汤Polyporus Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Prepare it as a decoction. Divide ē jiāo into 2 slices and melt them into the decoction.

Formula Indications Zhū Líng Tāng is indicated for patterns of binding water and heat. The symptoms are dysuria, fever, thirst with a desire to drink, vexation, insomnia, coughing, vomiting, nausea, and diarrhea. The tongue is red with a white or slightly yellow coating and the pulse is thready and rapid. It is also indicated for blood strangury marked by difficult, painful urination as well as pain and distension of the abdomen.

Analysis of Fundamental Pattern Pathogenesis

When external cold invasion reaches the interior, it may transform into heat and damage fluids. The result is the pattern of binding water and heat, which is associated with consumption of yin fluids. The binding of water and heat leads to the disorder of qi transformation and consumption of yin fluids. In this situation they may not ascend and thereby cause dysuria, fever, and thirst with a desire to drink. Yin deficiency with internal heat disturbs the heart and mind to cause vexation and insomnia. If water rushes up to hamper the lung qi and its ability to disperse and descend, cough will manifest. When water accumulates in the stomach, vomiting and nausea will manifest. When water pours into the large intestine, diarrhea will manifest. The red tongue with a white or slightly yellow coating and a thready and rapid pulse are all signs of yin deficiency with internal heat. The therapeutic methods are to promote urination, clear heat, and nourish yin. For patients with dysuria due to blood strangury, the therapeutic principles are to promote urination and relieve strangury, clear heat, and stanch bleeding.

Formula Actions Promotes urination, nourishes yin, and clears heat.

Formula Analysis

Unique Combination Features This formula promotes urination and percolates dampness, however, it also clears heat and nourishes yin. It presents the principle of promoting urination without damaging yin and nourishing yin without producing dampness.

Formula Applications 1. Essential pattern differentiation Zhū Líng Tāng is used for the pattern of binding of water and heat with yin deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of binding of water and heat with yin deficiency: urinary infection, nephritis, cystitis, and postpartum urinary retention. 4. Cautions and contraindications This formula is a water-draining and percolating formula. It is not applicable for patients with excessive internal heat marked by severe sweating with thirst.

Comparison & Contrast Wŭ Líng Săn vs. Zhū Líng Tāng

Case Studies 1. Chylous strangury A 7-year-old boy had chylous strangury for over one year. Whenever he urinated, it was painful and there was a white paste-like excretion in the urine. A careful examination of his urine revealed some small granular particles within the urine. The boy was skinny with a withered yellow complexion. His parents were very worried about him. Upon diagnosis, more than ten doses of Bì Xiè Fēn Qīng Yĭn (Hypoglaucae Root TurbidityClearing Beverage) were administered without effect. Then, the doctor asked for more detailed information about the boy. His family reported that the boy was often thirsty for cold drinks and also had night sweats. After learning this, the doctor suddenly understood that it was a yin deficiency syndrome. It is no wonder that the warming and astringent function of the prescription

could not help. Hence, zhū líng 12 g, fú líng 20 g, huá shí (wrapped) 18 g, ē jiāo (melt and take infused) 10 g, zé xiè 10 g, and lián zĭ 10 g were prescribed for the boy. Six doses later, the chyle urine ceased. Ten doses later, the boy was cured of this disease. Up until now, there has not been any recurrence of the disease.1 1 Li Fei. Advanced Collection of Traditional Chinese Medicine: Formulas 中医药学⾼级丛书· ⽅剂学. Beijing: People’s Medical Publishing House; 2002.

Comments: In this case of chylous strangury, the patient had once been mistreated due to wrong syndrome differentiation. This was a case of dampheat and yin deficiency. The proper treatment methods were to purge and clear heat, tonify yin, and avoid warming and astringent medicinals. Therefore, using Zhū Líng Tāng (Polyporus Decoction) to clear heat and dampness and to nourish yin with lián zĭ to clear heart fire and tonify yin will result in a good effect and the patient was cured. 2. Blood strangury A 36-year-old man suffered two years of repeated frequent urination. He had urgent, painful urination with hematuria that was accompanied by lumbar pain, polydipsia, and a propensity to sweat, etc. He was diagnosed with a right kidney stone in the internal medicine department and suggested to have surgery. The patient declined the surgery and asked to try Chinese medicinals instead. He had a pale complexion, flushed cheeks, thirst with a desire for drink yet only drank a little each time, feverish sensation of the palms and soles, poor appetite, palpitations with sweating, urinated over forty times with hematuria during the course of a day and night, and interrupted sleep. His pulse was weak and rapid. His tongue was red with a scanty coating. Zhū líng 30 g, zé xiè 15 g, fú líng 15 g, ē jiāo 15 g, huá shí 12 g, huáng băi 10 g, and zhī mŭ 10 g were decocted for him. After having five doses, the frequency of urination decreased to about twenty times per day.

The tidal fever and sweating also cleared. However, the hematuria increased so hēi zhī zĭ 10 g, dāng guī 15 g, and mŭ dān pí 10 g were added to the prescription for another five doses. After taking it, the blood in urine disappeared and the frequency of urination decreased to about ten times a day. The other symptoms improved in different degrees as well. A total of over fifty doses were prescribed with modifications based on the original prescription. After he took all of them, the clinical symptoms were basically cured. One more dose was administered as a bolus for consolidation.1 Comments: This case of blood strangury is due to fire from yin deficiency that burned the vessels and blocked the water passageway. It is correct to clear heat, tonify yin, and promote urination by applying Zhū Líng Tāng with appropriate modifications. Huáng băi and zhī mŭ clear the deficient fire induced by yin deficiency. Zhī mŭ, together with ē jiāo, tonifies yin and blood. Huáng băi with zé xiè purge flaming deficient fire. By the third visit, his symptoms had been relieved except for the hematuria. This suggested that the treatment had been appropriate for his situation and the damp-heat had been removed. Thereupon, the astringent hēi zhī zĭ was added along with dāng guī to lead blood flow within the vessels and mŭ dān pí to cool blood and prevent blood stasis. A good therapeutic effect was finally achieved.

Fáng Jĭ Huáng Qí Tāng 防⼰黄芪汤Stephania Root and Astragalus Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

1 Zhao Ming-rui. Elucidation on Classical Formulas 经⽅发挥. Taiyuan: Shanxi People’s Publishing House; 1982.

Preparation and Administration Prepare as a decoction with shēng jiāng and dà zăo.

Formula Indications Fáng Jĭ Huáng Qí Tāng is indicated for patterns of wind-water and wind-damp caused by an insecurity exterior due to exterior deficiency. The symptoms are sweating, aversion to wind, heavy body, slight swelling, pain of the limbs and joints, as well as dysuria. The tongue is pale with a white coating, and the pulse is floating.

Analysis of Fundamental Pattern Pathogenesis

Fáng Jĭ Huáng Qí Tāng is indicated for patterns of either wind-water or wind-dampness caused by wind-damp contraction in the exterior and waterdamp accumulation in the striae and interstitial spaces due to exterior deficiency and insecurity of wei qi. The nature of wind is open and dispersing. Therefore, when the exterior is deficient, ying-yin might be discharged causing sweating and wei qi might be insecure leading to aversion to wind. Dampness is sticky and turbid. Thus water-damp accumulation in the striae and interstitial spaces causes the body to feel heavy and develop mild swelling. Water-damp accumulation in the muscles, tendons, and bones results in pain of the limbs and joints. A pale tongue with a white coating and a floating pulse are signs of wind in the exterior. The therapeutic method is to induce sweating. Furthermore, methods to boost qi, consolidate the exterior, and dispel wind might be applied because of exterior deficiency.

Formula Actions Boosts qi and dispels wind, fortifies the spleen and promotes urination.

Formula Analysis

Unique Combination Features This formula combines the methods of dispelling wind, eliminating dampness, and fortifying the spleen with reinforcing zheng qi and dispelling pathogens. When wind-dampness is eliminated, the symptoms are relieved.

Formula Applications 1. Essential pattern differentiation Fáng Jĭ Huáng Qí Tāng is the common formula for wind-dampness and wind-water due to exterior deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of a wind-water or wind-dampness with exterior deficiency pattern: chronic glomerulonephritis, cardiac edema and rheumatic arthritis. 4. Cautions and contraindications This formula is not applicable for patients with severe swelling due to retention of water and dampness.

Case Studies 1. Wind-dampness (rheumatic arthritis) A 25-year-old woman had suffered from acute rheumatic disease with joint swelling and pain in the knees and elbows for over one month. After using various medications including penicillin, Vitamin B1, and aspirin, the swelling and pain was relieved. The remaining symptoms were persistent sweating, heavy sensation of the body, aversion to wind, a white and glossy tongue coating, and a floating and moderate pulse. This condition was due to unconsolidated wei yang allowing too much sweating and retained dampness to linger after dispelling the wind. The treatment plan was to boost wei yang in order to consolidate the exterior, eliminate dampness, and relieve the pain.

Modified Fáng Jĭ Huáng Qí Tāng (Stephania Root and Astragalus Decoction) was prescribed including: fáng jĭ 12 g, bái zhú 10 g, huáng qí 15 g, gān căo 3 g, shēng jiāng 3 slices, dà zăo 1 piece, fáng fēng 10 g, guì zhī 6 g and bái sháo (wine-fried) 10 g. After taking five doses, the sweating and aversion to wind stopped and the pain and swelling of the joints also improved.1 1 Tan Ri-qiang. Simple Description Essentials from the Golden Cabinet ⾦匮要略浅述. Beijing: People’s Medical Publishing House; 1981.

Comments: Dampness is yin, characterized by heaviness, turbidity, and stickiness. Disease induced by dampness occurs insidiously, and it is cured slowly. In this case, inducing heavy perspiration is not suggested because even if the wind is eliminated, the dampness may linger. It is better to do it slowly in order that both wind and dampness be dispelled. Fáng Jĭ Huáng Qí Tāng not only eliminates dampness and stops pain, but it also boosts wei qi to consolidate the exterior, reinforces zheng qi, and dispels pathogens. Used together with Guì Zhī Tāng, it dispels wind and harmonizes ying and wei in order to consolidate the exterior and assist the zheng qi. With fáng fēng, it dispels wind without hurting zheng qi. Handled in such a way, the disease can be gradually cured. 2. Wind edema A 40-year-old man came to see the doctor in June, 1973. His chief complaint was a heavy sensation of the lower limbs, edema of the shins, heel pain when tired from walking or standing, sweating and aversion to wind. His pulse was floating, deficient and rapid. His tongue was pale with a white coating. He was diagnosed with chronic nephritis as he had protein in the urine (++++) and RBC (+). Fáng Jĭ Huáng Qí Tāng was indicated. The prescription included: hàn fáng jĭ 18 g, shēng huáng qí 24 g, bái zhú 9 g, zhì gān căo 9 g, shēng jiāng 9 g, and dà zăo 4 pieces. After taking the formula

for ten months, the amount of protein in his urine decreased (+). After another two months, the protein in his urine disappeared and the other symptoms did as well.1 Comments: Chronic nephritis equals wind-edema in traditional Chinese medicine. He had been treated for a long time in vain. However, after taking Fáng Jĭ Huáng Qí Tāng prescribed by Doctor Yue for one year, the disease was cured. This case suggests that in treating chronic diseases, an experienced doctor should not change the prescription at will if the effect is not fast when the syndrome was differentiated correctly. At times it requires certain amounts of medicinals in order for the therapeutic effects be carried out.

Wŭ Pí Săn 五⽪散Five-Peel Powder Source Text Central Treasury Classic (Huá Shì Zhōng Cáng Jīng, 华氏中藏经)

Formula Ingredients

Preparation and Administration Prepare as a decoction. 1 Li Fei. Advanced Collection of Traditional Chinese Medicine: Formulas 中医药学⾼级丛书·⽅ 剂学. Beijing: People’s Medical Publishing House; 2002.

Formula Indications Wŭ Pí Săn is indicated for skin edema resulting from excessive dampness and spleen deficiency causing qi stagnation and water diffusion. The symptoms are general edema, heavy sensation of the body and limbs, fullness and distention of chest and abdomen, dyspnea, dysuria, and gestational edema. The tongue coating is white and greasy, and the pulse is deep and slow.

Analysis of Fundamental Pattern Pathogenesis

Skin edema is generally caused by excessive dampness overflowing into the skin. Waterdamp diffusion leads to general edema. Dampness is heavy, sticky, and turbid. It therefore might cause a heavy sensation of the body and limbs. Dampness tends to block qi movement resulting in fullness and distention of chest and abdomen. Failure of the lung qi to descend leads to dyspnea. The therapeutic methods are to promote urination, remove edema, rectify qi, and fortify the spleen.

Formula Actions Promotes urination and relieves edema, rectifies qi and fortifies the spleen.

Formula Analysis

Unique Combination Features

The five medicinals are peels. Peels are effective to promote qi and fluid movement in between the skin layers. In addition, it combines medicinals that promote urination and relieve edema with those that diffuse the lung and fortify the spleen. Qi movement might promote water movement which would then relieve skin edema. Wŭ Pí Yĭn recorded in Book to Safeguard Life Arranged for Measles (Má Zuì Kē Huó Rén Quán Shū, 麻科活⼈全书) contains wŭ jiā pí without sāng bái pí. It has similar indications associated with actions to dispel wind and dredge collaterals. Wŭ Pí Săn recorded in Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅) contains wŭ jiā pí and dì gŭ pí, without sāng bái pí and chén pí. Its ability to move qi is not strong.

Formula Applications 1. Essential pattern differentiation Wŭ Pí Săn, bland in nature, is the common formula for skin edema. The clinical pattern is marked by:

● general edema ● fullness and distention of chest and abdomen ● dysuria 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of excessive dampness accumulation in the spleen: nephritis edema, cardiac edema, and gestational edema.

Case Studies Infantile edema A child had general edema accompanied with a herniated navel, swollen scrotum, unable to turn over while lying supine, extremely scanty urine (only 50 ml urine daily), cough, and fever. Furosemide, sorbitol, and a plaster of pharbitis seed were all applied yet edema remained. Wŭ Líng Săn (Five Substances Powder with Poria) and Wŭ Pí Yĭn (Five-Peel Beverage) were applied with added jié gĕng and xìng rén in order to diffuse the lung qi. After taking it, the urine output increased significantly. This was associated with the relief of the edema. Food intake increased from 0 to 150-180 g per day. Formulas to supplement the kidney and promote urination were applied once the edema was generally under control. Eventually the edema was cured.1 Comments: Edema with a herniated navel and swollen scrotum is a critical condition for kids. According to the therapeutic method of treating the branch in urgent conditions, Wŭ Líng Săn and Wŭ Pí Yĭn were used to promote transformation of qi and promote urination to relieve the edema.

Meanwhile, jié gĕng and xìng rén were used to diffuse the lung qi. The lung governs the qi of the entire body. When the lung qi disperses and descends, the water passages may be free and regulated. This is an important aspect of water descending into the bladder. Additionally, when edema is reduced and the appetite improves, the therapeutic method necessarily changes to supplement the kidney and promote urination to treat the root and branch simultaneously. Without profound comprehension of the therapeutic methods described in The Yellow Emperor’s Inner Classic, one cannot achieve such agility. 1 Yue Mei-zhong. Medical Discourses of Yue Mei-zhong 岳美中医话集. Beijing: People’s Medical Publishing House; 2005.

Section 4 Cold-Damp Warming and Resolving Formulas Cold-damp warming and resolving formulas are applied to phlegm, rheum, and edema caused by either yang deficiency that has failed to transform water or dampness that has transformed into colddampness. Common medicinals found within yang-warming formulas include gān jiāng, guì zhī, and fù zĭ. They are often combined with medicinals that fortify the spleen and eliminate dampness, such as fú líng and bái zhú. Common formulas in this category are Líng Guì Zhú Gān Tāng, Zhēn Wŭ Tāng and Shí Pí Săn.

Líng Guì Zhú Gān Tāng 苓桂术⽢汤Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略)

Formula Ingredients

Preparation and Administration Prepare as a decoction and drink it warm.

Formula Indications Líng Guì Zhú Gān Tāng is indicated for phlegm-rheum due to deficiency of the middle-yang. The symptoms are distention and fullness of chest and rib-side, dizzy vision, palpitations, shortness of breath, and cough. The tongue coating is white and glossy. The pulse is either wiry and slippery or deep and tight.

Analysis of Fundamental Pattern Pathogenesis This formula is applied to patterns of phlegm-rheum caused by deficiency of middle-yang and the failure of the transformation and transportation of the spleen which leads to disorder of qi transformation and the retention of water and dampness. The spleen lies in the middle jiao and governs qi transformation. It acts as an axis of qi ascension and descending; therefore, when the spleen yang is deficient, its transformation and transportation are affected. The result is dampness accumulation which further develops into phlegm-rheum. Phlegm and rheum ascend and descend as qi moves. Consequently, they can exist anywhere. When they accumulate in chest and rib-side, distention and fullness of chest and rib-side may be seen. When they block the middle jiao and cause a disorder of clear yang ascension, dizziness and vertigo may be seen. When they invade the heart and lung, palpitations, shortness of breath, and cough might be seen. A white and glossy tongue coating, wiry and slippery pulse, and deep and tight pulse are all signs of retention of phlegmrheum.

Zhang Zhong-jing said that “one who suffers from phlegm-rheum should be regulated by warm medicinals”[1] (recorded in Essentials from the Golden Cabinet). The therapeutic methods are to warm yang and dissolve rheum, fortify the spleen and promote urination.

Formula Actions Warms yang and dissolves rheum, fortifies the spleen and drains dampness.

Formula Analysis

Unique Combination Features

This formula combines medicinals that warm yang and fortify the spleen to help dissolve rheum with medicinals that percolate and drain dampness with a bland flavor in order to calm surging and direct counterflow downward. It is warm but not dry, reducing but not drastic, and it focuses on both the root and branch aspects. It is well organized as an essential harmonizing formula for treating phlegm-rheum. Urine output might increase after taking this formula. It is a sign of fluid reduction, and is said in the original book that urination may later be promoted. This is also similar to the saying in the Essentials from the Golden Cabinet that for mild fluid accumulation complicated by shortness of breath, the therapeutic method is to eliminate the fluid by promoting urination.

Formula Applications 1. Essentials of pattern differentiation This formula is the representative formula for treating phlegm-rheum due to middle yang deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of water and fluid retention in the

middle jiao: chronic bronchitis, bronchial asthma, cardiac edema, edema in chronic glomerulonephritis, Meniere’s syndrome, and neurosis. 4. Cautions and contraindications It is not applicable for patients with phlegm transformed into heat marked by cough with sticky sputum.

Associated Formulas Gān Căo Gān Jiāng Fú Líng Bái Zhú Tāng (Licorice, Dried Ginger, Poria and Atractylodes Macrocephalae Decoction, ⽢草⼲姜茯苓⽩术 汤) [Source] Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) [Ingredients] Líng Guì Zhú Gān Tāng with gān jiāng instead of guì zhī. [Preparation and Administration] Prepare it as a decoction. [Actions] Warms the spleen and overcomes dampness. [Applicable Patterns] Cold-dampness invasion in the kidney. Symptoms include: cold pain and heaviness of waist, normal appetite, absence of thirst, dysuria, a pale tongue body, a white tongue coating, and a slow and deep or deep and moderate pulse.

There is only one medicinal that differs from Líng Guì Zhú Gān Tāng in this formula. Líng Guì Zhú Gān Tāng, as a yang-warming and rheumdissolving formula, combines fú líng and guì zhī as a pair, one for warming and one for reducing. Its primary function is to dispel water and fluids. Líng Guì Zhú Gān Tāng is used for phlegm accumulation under the heart due to deficiency of the middle yang manifesting distention and fullness of the chest and rib-side, dizziness, and palpitations. Gān Căo Gān Jiāng Fú Líng Bái Zhú Tāng uses gān jiāng to warm the center and dispel cold. It is assisted by fú líng and bái zhú to dispel dampness and fortify the spleen. Its main objective is to dispel colddampness and its primary function is to warm the center, dissipate cold, and dispel dampness. It is used for kidney fixed bì due to cold-damp invasion manifesting a heavy waist and cold pain.

Comparison & Contrast Wŭ Líng Săn vs. Líng Guì Zhú Gān Tāng

Case Studies 1. Thirst A 39-year-old female worker came to see the doctor on March 18th, 1986 for the first time. She said that she was thirsty yet had no desire to drink, had dryness of the throat and nose, nausea, and a cold sensation in her pharynx and palate with sticky sputum. Over the last three years, all the treatments she underwent were ineffective although her symptoms would be relieved after she expectorated sputum. Her tongue was pale with teethmarks and a thin, white and moist coating. Her pulse was deep, thready and wiry. It was a pattern of phlegm-rheum obstruction in the orifices with a disorder of fluid distribution. The therapeutic method was to warm and dissolve phlegm-rheum and unblock the orifices. Líng Guì Zhú Gān Tāng plus jiāng bàn xià, bái jiè zĭ, xì xīn, and jié gĕng were applied. After taking three doses, the phlegm-rheum dissolved, the orifices were unblocked, and the body fluids were redistributed to the body. The disease was cured with no recurrence over the past three months noted during follow-up.1 1 Huang Rui-bin. Clinical Experience of Líng Guì Zhú Gān Tāng 苓桂术⽢汤临证治验. Heilongjiang Journal of Traditional Chinese Medicine. 1987; (3):19.

Comments: Phlegm-rheum can either ascend or descend because qi moves anywhere in the body. Therefore, it is said that odd diseases are mostly associated with phlegm. In this case, thirst was caused by the failure of fluid distribution due to phlegm stagnation in the orifices. Líng Guì Zhú Gān Tāng was used to warm and dissolve phlegm-rheum. Bàn xià and bái jiè zĭ dry dampness and dissolve phlegm. Xì xīn and jié gĕng ventilate the lung orifice to facilitate qi movement in the upper jiao which, in turn, leads to the smooth distribution of body fluid. This case reveals that thirst is not only caused by yin deficiency, but rather a failure of the distribution of body fluids due to phlegmrheum stagnation.

2. Insomnia A 45-year-old female government officer had her first visit on December 15th, 1980. Her chief complaint was insomnia after waking up in the night, with an average sleeping time of only three to four hours daily for over ten years. She reported dizziness, headache, lassitude, shortness of breath, poor memory, lack of appetite, and easily getting distracted. Her tongue coating was white, and her pulse was deep and thready. This was caused by dampness disturbing the clear orifices due to yang deficiency and dysfunction of the spleen. The therapeutic methods were to warm yang and dissolve rheum, raise the clear, and remove turbidity. Líng Guì Zhú Gān Tāng plus huáng qí, shān yào, yuăn zhì, chāng pú, ròu guì, gōu téng and shēng má were applied. She was cured by twelve doses.1 Comments: In this case, yang deficiency of the spleen gives rise to poor transformation and transportation. This leads to internal cold-dampness which further develops into turbidity. Turbidity disturbs the orifices and obstructs the rising of clear yang marked by dizziness, insomnia, and so on. Líng Guì Zhú Gān Tāng with ròu guì can warm and dissolve rheum. With huáng qí and shēng má it boosts qi and banks the origin, holds up the clear yang, and nourishes the head. With gōu téng, yuăn zhì, and chāng pú it dispels wind, dampness, and rheum, opens the orifices and awakens the mind. With phlegm-rheum dissolved, clear yang can rise and prenatal qi is reinforced. One can certainly think quickly at day and sleep soundly at night.

Zhēn Wŭ Tāng 真武汤True Warrior Decoction Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration Prepare as a decoction and drink while it is warm.

Formula Indications 1 Zhou De-lin, Zhou Lian-xiang. The Clinical Application of Líng Guì Zhú Gān Tāng 苓桂术⽢ 汤的临床应⽤. Jilin Journal of Traditional Chinese Medicine. 1987; (3): 26.

Zhēn Wŭ Tāng is indicated for edema due to yang deficiency. The symptoms are fear of cold, cold limbs, urination disturbance, palpitations under the heart, dizziness, muscular twitching, unsteady standing, pain and heaviness of four limbs, edema especially below the waist, abdominal pain, diarrhea, cough, asthma, vomiting and nausea. The tongue is pale and enlarged with teethmarks with a white glossy coating, and the pulse is deep and thready.

Analysis of Fundamental Pattern Pathogenesis

Zhēn Wŭ Tāng is the fundamental formula used to treat an overflow of water-dampness caused by deficiency of spleen-kidney yang. The spleen restricts water and the kidney governs water. Spleen yang deficiency leads to dysfunction of the transformation and transportation of water, while kidney yang deficiency leads to the dysfunction of dispersion and distribution of water. Both lead to water retention in the interior. Kidney yang deficiency leads to cold-water retention in the interior with urination disturbance. Furthermore, water-dampness spills over and diffuses into the limbs to cause heaviness and pain of the limbs and swelling of the body and limbs. Waterdampness pours downward into the bowels to cause abdominal pain and diarrhea. It rushes up to the lung and stomach to cause coughing and vomiting, and when it invades the heart there are palpitations. Waterdampness blocks the middle jiao which inhibits the clear yang from rising and causes dizziness. If there is too much sweat loss that occurs when inducing sweat-promotion in a taiyang syndrome, yin and yang might be consumed. The result is a loss of warmth and fluid invasion into the muscles and tendons causing muscular twitching and unsteadiness while standing. For water overflowing due to yang deficiency, the therapeutic methods are to warm yang and promote urination.

Formula Actions Warms yang and promotes urination.

Formula Analysis

Unique Combination Features This formula combines methods of warming yang with promoting urination. It is effective for edema due to yang deficiency. It also combines the methods of percolating and draining dampness with drying dampness and expelling water accumulation. This formula treats the root and branch simultaneously; however, it is focused on the root. The spleen and kidney are both involved but the focus is on warming the kidney.

Formula Applications 1. Essential pattern differentiation Zhēn Wŭ Tāng is the basic formula used to warm yang and promote urination. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of spleen-kidney yang deficiency with retention of water-dampness: chronic glomerulonephritis, cardiac edema, hypothyroidism, chronic bronchitis, chronic enteritis, and tuberculosis of the intestines.

Associated Formulas Fù Zĭ Tāng (Aconite Decoction, 附⼦汤) [Source] Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论) [Ingredients] Zhēn Wŭ Tāng with a heavy dose of fù zĭ and bái zhú, and rén shēn is used instead of shēng jiāng. [Preparation and Administration]

Prepare it as a decoction. [Actions] Warms the channels and assists yang, dispels cold and removes dampness. [Applicable Patterns] Cold-damp invasion interiorly. Symptoms include: joint pain, aversion to co1d, cold limbs, a white and glossy coating, and a deep and faint pulse. Only one medicinal differs between Fù Zĭ Tāng (Aconite Decoction) and Zhēn Wŭ Tāng. They are both applied to kidney yang deficiency with overflowing of water-dampness. Fù Zĭ Tāng uses a heavy dose of fù zĭ and bái zhú combined with rén shēn to warm and supplement the spleen-yang in order to dispel colddampness. Zhēn Wŭ Tāng uses half the dose of fù zĭ and bái zhú found in Fù Zĭ Tāng (Aconite Decoction). They are assisted by shēng jiāng to warm and supplement the kidney yang in order to disperse waterdampness.

Case Studies 1. Edema A man surnamed Kang reported edema in all four limbs, a cold sensation especially in the lower limbs, scanty urine, and abdominal distention. His pulse was deep and faint. Zhēn Wŭ Tāng was applied. The prescription was composed of fú líng 12 g, bái zhú 12g, bái sháo (dry-fried) 9 g, fù zĭ (processed) 9 g, and shēng jiāng 9 g. After taking four doses, the urine output increased. Another several doses were administered and his

edema was relieved. However, he had diarrhea at night. Thus, Shí Pí Yĭn (Spleen-Strengthening Beverage) was prescribed to arrest diarrhea and prevent the recurrence of edema.1 Comments: Edema with cold lower limbs as well as a deep and faint pulse is caused by spleenkidney yang deficiency. The kidney governs water and the spleen controls water. Yang deficiency of the spleen and kidney allows water to flow out of control causing flooding of the body fluids marked by edema and scanty urine. Zhēn Wŭ Tāng boosts prenatal yang qi to counter the over-abundance of yin, reinforces the spleen to dredge the water passage way, and relieves edema by promoting urination. Diarrhea at night is a sign of yang deficiency and water pouring in the intestines. Shí Pí Yĭn with the actions to warm yang and fortify the spleen can arrest diarrhea, promote urination, and remove edema in order to prevent reoccurrence. 2. Dizziness Ma, a 70-year-old female, reported having hypertension for three years complicated with dizziness, headache, tinnitus aggravated by tiredness, increasing body weight, occasional incontinence of urine, frequent urination at night, excessive sputum, fear of cold, cold hands and feet, abdominal distention after drinking, and a preference for hot drinks. The pulse was deep and thready, especially on the right side, and her tongue was pale with a glossy coating. It was a syndrome of yang deficiency and water counterflow. The therapeutic methods were to warm yang qi in order to control water and fortify the spleen to dissolve phlegm. The prescription included fú líng 3 qian, shēng bái zhú 2 qian, bái sháo 2 qian, fù piàn 2 qian, shēng jiāng 1.5 qian, fă bàn xià 3 qian, shēng lóng gŭ 4 qian, and shēng mŭ lì 4 qian. By the second visit, her dizziness was relieved and she slept better. Her blood pressure was still high and the tongue and pulse remained the same.

The same prescription with added wŭ wèi zĭ 1 qian and guī băn 4 qian was applied. On the third visit she reported slight dizziness and headache. Her spirit improved, her urination was normal, and she only had a little phlegm. Her tongue coating was thin and her pulse was deep, thready and slippery. The same prescription with added chén pí 1.5 qian and bái jiè zĭ (dry-fried) 2 qian was applied. After taking the formula, the blood pressure became stable and her symptoms were significantly relieved.2 Comments: In this case, the symptoms of dizziness and headache, tinnitus, poor hearing, fear of the cold, cold limbs, frequent urination, incontinence of urination, a pale tongue, and a deep, thready pulse are signs of yang deficiency. Excessive sputum and glossy tongue coating indicate water retention due to yang deficiency of the spleen and kidney. When yang qi fails to transform water, clear yang cannot ascend so turbid water counterflows upward. Thus, Zhēn Wŭ Tāng is used to warm yang and control water. Bàn xià is used to resolve dampness and eliminate phlegm. Lóng gŭ and mŭ lì are used to restrain the counterflow of water. Once the symptoms were relieved, wŭ wèi zĭ and guī băn were added to nourish yin and astringe yang, and chén pí and bái jiè zĭ are added to dissolve phlegm. 1 Chinese Academy of TCM. TCM Medical Records and Notes of Yue Mei-zhong 岳美中医案集. Beijing: People’s Medical Publishing House; 1978. 2 Chinese Academy of TCM. Medical Experience of Pu Fu-zhou 蒲辅⾈医疗经验. Beijing: People’s Medical Publishing House; 1976.

Shí Pí Săn 实脾散Spleen-Strengthening Powder Source Text Yan’s Revised and Expanded Formulas to Aid the Living (Chóng Dìng Yán Shì Jì Shēng Fāng,重订严氏济⽣⽅)

Formula Ingredients

Preparation and Administration Add shēng jiāng and dà zăo, and prepare the formula as a decoction.

Formula Indications Shí Pí Săn is indicated for a pattern of yin edema caused by spleenkidney yang deficiency and retention of water-dampness in the interior. The symptoms are swelling of the lower limbs, cold hands and feet, no thirst, fullness and distention of chest and abdomen and loose stool. The tongue coating is white and greasy and the pulse is deep, wiry and slow.

Analysis of Fundamental Pattern Pathogenesis Edema in this pattern is caused by spleen-kidney yang deficiency leading to retention of waterdampness in the interior. Excessive waterdampness in the interior that overflows to the skin leads to swelling of limbs. Water is a yin pathogen that is descending in nature so it is recognized by swelling of the lower limbs. When spleen-kidney fails to warm the body there will be cold hands and feet. Blockage of qi movement due to water accumulation leads to fullness and distention of chest and abdomen. Spleen yang deficiency results in loose stool caused by impaired decomposing and distention of food and water. Absence of thirst, a white and greasy tongue coating, and a deep, wiry and slow pulse are also signs of yang deficiency. The therapeutic methods are to warm yang and fortify the spleen, move qi, and promote urination.

Formula Actions Warms yang and fortifies the spleen, moves qi, and promotes urination.

Formula Analysis

Unique Combination Features This formula treats the spleen and kidney simultaneously; however, warming the spleen yang is its primary function. This formula combines the qi-moving method with the warming and reducing method because dampness is removed when qi moves smoothly.

Formula Applications

1. Essential pattern differentiation Shí Pí Săn is the commonly used formula to treat edema due to spleenkidney yang deficiency. This clinical pattern is marked by:

2. Modifications

Continued

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of spleen-kidney yang deficiency and qi stagnation: chronic glomerulonephritis, cardiac edema, and cirrhosis. 4. Cautions and contraindications It is not applicable for patients with yang edema.

Comparison & Contrast Zhēn Wŭ Tāng vs. Shí Pí Săn

Case Studies Edema A man suffered from edema of his whole body. He also had abdominal distention, a pale complexion, normal defecation and urination, no thirst, and little desire for food. His pulse was slow (three beats in one breath) and his tongue had a white and glossy tongue coating. All of the above symptoms suggested that his edema was induced by excessive pathogenic yin. Therefore, Shí Pí Săn was prescribed containing hòu pò, bái zhú, mù guā, dà fù pí, fù zĭ, mù xiāng, căo guŏ, fú líng, gān jiāng, and shēng jiāng. After taking five doses, the edema gradually disappeared. Then five doses of the same prescription with lóu gū (2 pieces ground to powder, taken with the decoction) were prescribed and the disease was cured. Whenever I use this

prescription to treat edema caused by cold yin pathogens, it always succeeds.1 Comments: The edema in this case was caused by insufficient spleen yang causing fluid retention. When spleen yang is deficient, there is a pale complexion and little desire for food. Fluid retention in the body and disturbed qi movement will result in overall edema, abdominal distention, and so on. This prescription was prescribed to warm yang, fortify the spleen, and move qi in order to promote urination. The medicinals match the symptoms so the edema reduced. Lóu gū was added to the prescription on the second visit to strengthen the function of promoting urination and a good therapeutic effect was brought about.

Bì Xiè Fēn Qīng Săn 萆薢分清散Hypoglaucae Root Turbidity-Clearing Powder a.k.a. Bì Xiè Fēn Qīng Yĭn (Hypoglaucae Root Turbidity-Clearing Beverage, 萆薢分清饮) Source Text Secret Formulas of the Yang Family (Yáng Shì Jiā Cáng Fāng, 杨氏家 藏⽅)

Formula Ingredients

Preparation and Administration Prepare as a decoction and add some salt to it.

Formula Indications Bì Xiè Fēn Qīng Săn is indicated for chylous strangury and gonorrhea due to deficiency-cold of the lower jiao. The symptoms are frequent turbid urination that is white like rice-washed water and mushy or creamy. The tongue is pale with a white coating, and the pulse is deep.

Analysis of Fundamental Pattern Pathogenesis

This pattern is caused by deficiency-cold of the lower jiao leading to stagnation of turbid dampness. Deficiency-cold of the lower jiao leads to a disorder of qi transformation. As a result, the kidney fails to store and the bladder restricts the urine. This condition is marked by frequent urination, turbid white urine that is like mush and cream. The therapeutic methods are to warm the lower jiao, drain dampness, and remove turbidity. 1 Hunan Institute of Traditional Chinese Medicine. Cases of Experienced TCM Physicians of Hunan Province 湖南省⽼中医医案选. Changsha: Hunan Science and Technology Press; 1980.

Formula Actions Warms the kidney and drains dampness, raises the clear and removes turbidity.

Formula Analysis

Unique Combination Features

This formula drains dampness and removes turbidity to treat the branch, and warms the lower jiao to treat the root. This formula named “Bì Xiè Fēn Qīng Săn” is originally from Secret Formulas of the Yang Family (Yáng Shì Jiā Cáng Fāng, 杨氏家藏⽅) written by Yang Tan in the South Song Dynasty. In the Yuan Dynasty, Zhu Dan-xi quoted it in Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法) and changed its name to Bì Xiè Fēn Qīng Yĭn.

Formula Applications 1. Essential pattern differentiation Bì Xiè Fēn Qīng Săn is a frequently used formula to treat chylous strangury or gonorrhea due to deficiency-cold of the lower jiao. This clinical pattern is marked by:

● frequent and turbid urination ● pale tongue and white coating ● deep pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of deficiency-cold of the lower jiao

and turbid dampness: chyluria, chronic prostatitis, chronic pyelonephritis, chronic nephritis and chronic pelvic inflammation. 4. Cautions and contraindications It is not applicable for patients with damp-heat gonorrhea.

Associated Formulas Bì Xiè Fēn Qīng Yĭn (Hypoglaucae Root Turbidity-Clearing Beverage, 萆薢分清饮) [Source] Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and drains dampness, raises the clear and removes turbidity. [Applicable Patterns] Damp-heat gonorrhea. Symptoms include: turbid urine, dripping urination, and a yellow and greasy coating. Both Bì Xiè Fēn Qīng Săn and Bì Xiè Fēn Qīng Yĭn combine bì xiè and shí chāng pú to drain dampness and separate the clear from the turbid.

Bì Xiè Fēn Qīng Săn from Secret Formulas of the Yang Family combines warm natured yì zhì rén and wū yào to warm the lower jiao. It is used to treat to gonorrhea due to deficiency-cold of lower jiao. Bì Xiè Fēn Qīng Yĭn from Medical Revelations combines cold natured huáng băi and chē qián zĭ to clear heat and drain dampness. It is used to treat gonorrhea due to damp-heat.

Case Studies Chylous strangury A 70-year-old man reported that he had suffered chylous strangury for many years. He had frequent painful urination with rice juice-like or milklike urine. His condition was due to kidney depletion, damp-heat pouring downward, and the bladder failing to transport and transform water. Other symptoms were insomnia, lassitude, fatigue, and poor appetite. It is a condition that is hard to treat using only the nourishing method. So, the first step was to boost qi and fortify the spleen with the diffusing and transforming method in order to dredge the water passageways. So, Bì Xiè Fēn Qīng Yĭn and Zī Shèn Tōng Guān Wán (Kidney-Nourishing and Orifices-Opening Pill) were prescribed to clear turbid dampness and warm the kidney in order to transform qi. He also had signs of strangury due to overstrain because of old age and qi sinking. However, the dominate pathogen was excessive damp-heat creating a dampness within deficiency syndrome. Shēng huáng qí, shān yào, fú shén, bái zhú, nǚ zhēn zĭ (processed), yì zhì rén, wū yào, fĕn bì xiè, shēng gān căo shāo, xiăo mài, hé huān pí, and Zī Shèn Tōng Guān Wán 1 qian (wrapped) were prescribed for the patient.1 1 Shanghai University of Traditional Chinese Medicine. Cheng Men-xue Medical Cases 程门雪 医案. Shanghai: Shanghai Scientific and Technical Publishers; 1982.

Comments: The elderly patient had reached the age of kidney deficiency and suffered from strangury for a long time. The kidney and spleen must have been damaged badly. Spleen deficiency caused the sinking of center qi and the kidney deficiency caused the failure to store essence and control urination. The symptoms were frequent urination with turbid milklike urine. Although the condition had been there for a long time, the painful urination suggested that damp-heat was still in the body and formed a syndrome of excess and deficiency. Therefore, neither simply dispelling the pathogens nor reinforcing zheng qi could be applied. The suitable treatment was to warm the kidney, promote transformation of qi, and clear damp-heat simultaneously. Bì Xiè Fēn Qīng Yĭn was used to warm the kidney, drain dampness, and remove turbidity. The Zī Shèn Tōng Guān Wán was used to clear damp-heat and transform qi in order to promote urination. Huáng qí, bái zhú, and shān yào were added to boost qi and fortify the spleen. Fú shén, xiăo mài, and hé huān pí were added to treat insomnia due to heart qi deficiency by nourishing the heart and calming the mind. All the medicines above can regulate the heart, spleen, and kidney at the same time. It is truly a good prescription for the elderly with chylous strangury.

Section 5 Wind-Dispelling and Dampness-Overcoming Formulas Wind-dispelling and dampness-overcoming formulas can be applied to treat headaches and heavy body sensation caused by wind-dampness in the exterior or numbness and pain of the waist caused by wind-dampness invading channels and collaterals. Commonly used wind-expelling and dampness-overcoming medicinals include qiāng huó, dú huó, fáng fēng, qín jiāo, and sāng jì shēng. Common formulas in this category are Qiāng Huó Shèng Shī Tāng and Dú Huó Jì Shēng Tāng.

Qiāng Huó Shèng Shī Tāng 羌活胜湿汤 Notopterygium Dampness-Drying Decoction Source Text Treatise on the Spleen and Stomach (Pí Wèi Lùn, 脾胃论)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications Qiāng Huó Shèng Shī Tāng is indicated for bì syndrome caused by wind-dampness in the exterior. The symptoms are pain of the shoulder and back, headache and heavy body sensation, and pain of the waist and spine that make the patient unable to turn over. The coating is white and the pulse is floating.

Analysis of Fundamental Pattern Pathogenesis This formula treats wind-dampness lying in the exterior caused by wind invasion while sweating, living in a damp place for a long time, or winddamp invasion. Pathogenic wind-dampness invades the hand taiyang channel and blocks its qi causing a headache and heavy body sensation and pain of the waist and spine that makes the patient unable to turn around. Since wind-cold lies in the exterior and because it is proper to induce sweating, the proper treatment is to dispel wind and overcome dampness.

Formula Actions Dispels wind, overcomes dampness, and relieves pain.

Formula Analysis

Unique Combination Features This formula contains many acrid and warm medicinals prescribed at a low dose that ascend and disperse with mild function. It dispels exterior wind and mildly promotes sweating.

Formula Applications 1. Essential pattern differentiation Qiāng Huó Shèng Shī Tāng is a frequently used formula used to treat headache and heavy body sensation due to wind-dampness in the exterior and a mild exterior syndrome. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs and symptoms of exterior winddampness such as rheumatic arthritis, rheumatoid arthritis, hyperostosis, and ankylosing spondylitis.

Associated Formulas Juān Bì Tāng (Painful Obstruction-Eliminating Decoction, 蠲痹汤) [Source] Secret Formulas of the Yang Family (Yáng Shì Jiā Cáng Fāng, 杨氏家 藏⽅) [Ingredients]

[Preparation and Administration] Cut the medicinals into pieces. One dose is 0.5 liang (15 g). Add 2 zhan of water and decoct it with 5 pieces of shēng jiāng and 3 pieces of dà zăo until 1 zhan water remain, remove the dregs and take it warm.

[Actions] Boosts qi and harmonizes ying, dispels wind and overcomes dampness. [Applicable Patterns] Wind-cold-dampness blocking the channels. Symptoms include: pain of the shoulder, arms, and back, difficult to move, and numbness of the hands and feet.

Comparison & Contrast Jiŭ Wèi Qiāng Huó Tāng vs. Qiāng Huó Shèng Shī Tāng

Continued

Case Studies Headache

I have treated a patient who was over 30 years old and had suffered from a headache for half of a year and was treated with no effect. Seeking treatment for the disease, he has spent almost all his money and was tortured all the way by his enduring headache. His symptoms at the time of his intake included a floating and soggy pulse, a thin and white tongue coating, normal diet, heaviness of the head as if it was wrapped with cloth, and a continuous headache. After learning this I felt that the failure to cure his disease in half a year’s time was caused by his former doctor’s mistreatment. A headache with a sensation of being wrapped, a white tongue coating and a soggy pulse are all signs of dampness. The treatment principle was to dispel the wind and dissipate dampness. Based on the saying “only medicinals with a light nature can rise to the upper jiao and carry out its efficacy”, medicinals that were light and had diffusing and ventilating actions were selected. The prescription was composed of jīng jiè suì 12 g, fáng fēng 10 g, chuān xiōng 10 g, bái zhĭ 6 g, găo bĕn 3 g, cāng zhú 12 g, qiāng huó 6 g, guì zhī 6 g, and gān căo 3 g. After taking the first dose, he had a mild sweat and the headache was relieved. With one more dose, the headache disappeared.1 Comments: The headache was caused by dampness overwhelming the clear orifices. Due to the sticky quality of the dampness and the previous mistreatments, the headache “survived for a long time”. In fact, dampness should be dissipated by using aromatic medicinals that lift the clear yang. Therefore, down bearing dú huó was removed and up bearing jīng jiè suì was added to help qiāng huó lift and diffuse. Bái zhĭ, which took place of màn jīng zĭ, not only clears the mind and stops the pain, but it also dissipates dampness and ventilates the upper jiao, especially with aromatic cāng zhú. Guì zhī was included because of its ability to warm and dissipate dampness and distributing yang qi. In this way, the patient finally got rid of his stubborn headache.

Dú Huó Jì Shēng Tāng 独活寄⽣汤Pubescent Angelica and Mistletoe Decoction Source Text Important Formulas Worth a Thousand Gold Pieces for Emergency (Bèi Jí Qiān Jīn Yào Fāng,备急千⾦要⽅) 1 Li Fei. Advanced Collection of Traditional Chinese Medicine: Formulas 中医药学⾼级丛书·⽅ 剂学. Beijing: People’s Medical Publishing House; 2002.

Formula Ingredients

Preparation and Administration

Prepare as a decoction.

Formula Actions This formula is indicated for long-term bì syndrome associated with deficiency of the liver and kidney and insufficiency of qi and blood. The symptoms include pain and flaccidity of the waist and knees, disorder of flexion and extension of the joints, numbness, fear of cold with a preference for warmth, palpitations, and shortness of breath. The tongue is pale with a white coating and the pulse is thready and weak.

Analysis of Fundamental Pattern Pathogenesis Dú Huó Jì Shēng Tāng is a frequently used formula for long-term bì syndrome caused by liver and kidney deficiency, and qi and blood insufficiency. It is generally caused by the contraction of wind-colddampness which, over a long period of time, leads to bì syndrome. The liver and kidney are involved and there is consumption of qi and blood. Windcold-damp invasion in the limbs and joints leads to qi and blood blockage that cause pain of the waist and knee. Gradually, stiffness and numbness of the limbs and joints might be seen. It is said in the Basic Questions that bì in the bones results in heaviness, while bì in the channels results in numbness. Additionally, the kidney governs bone and the liver governs sinews. When pathogens invade the sinews and bones for a long time, the liver and kidney might be damaged with consumption of qi and blood. Consequently, weakness of the waist and knee occurs as the waist is the residence of the kidney and the knees are the residence of the tendons. Qi and blood consumption leads to palpitations and shortness of breath. It is said in Basic Question that deficiency of ying qi gives rise to numbness, while deficiency of wei qi gives rise to flaccidity, and deficiency of both ying and wei qi give

rise to numbness and flaccidity. Zheng qi deficiency and pathogenic excess are involved in this pattern; therefore, the therapeutic methods are to reinforce zheng qi and dispel pathogens. Expel wind-cold-dampness on the one hand and boost the liver and kidney and supplement qi and blood on the other hand.

Formula Actions Dispels wind-dampness, relieves pain, boosts the liver and kidney, supplements qi and blood.

Formula Analysis

Unique Combination Features This formula primarily dispels wind-cold-dampness. However, it also supplements the liver and kidney and boosts qi and blood. It addresses both

the pathogenic qi and zheng qi. It dispels pathogens without damaging zheng qi and reinforces zheng qi without keeping the pathogens inside.

Formula Applications 1. Essential pattern differentiation Dú Huó Jì Shēng Tāng is a frequently used formula for long-term bì syndrome caused by liverkidney deficiency and qi and blood insufficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of long-term bì due to wind-colddampness with deficiency of zheng qi: chronic arthritis, rheumatoid arthritis, rheumatic sciatica, lumbar muscle strain, hyperostosis, and infantile paralysis. 4. Cautions and contraindications This formula is not applicable for patients with an excess pattern of bì caused by damp-heat.

Associated Formulas Sān Bì Tāng (Three Impediments Decoction, 三痹汤) [Source] Corrections and Annotations to Fine Formulas for Women (Jiào Zhù Fù Rén Liáng Fāng, 校注妇⼈良⽅) [Ingredients]

[Preparation and Administration] Grind the medicinals into powder. One dose is 5 qian (15 g). Add 2 zhan of water and decoct it with 3 pieces of shēng jiāng and 1 piece of dà zăo until 1 zhan water remain, remove the dregs and take it warm. [Actions] Boosts qi and invigorates blood, dispels wind and eliminates dampness. [Applicable Patterns] Long-term bì with consumption of qi and blood. Symptoms include: stiffness of the hands and feet, problems with the flexion and extension of joints, numbness of joints, a white tongue coating, and a thready or choppy pulse.

Case Studies Bì syndrome A patient suffered with pain of the lower back and buttocks that radiated to the medial thighs. It was accompanied by vomiting watery saliva when the pain was worse, decreased appetite, and difficulty in turning about the bed. The lumbar is the house of shaoyin, the taiyang channel is on the buttock, and the jueyin channel is on the medial thigh. Postpartum blood deficiency gave way to a wind-cold-damp invasion that further invaded the collaterals of taiyang, shaoyin and jueyin. The ying and wei qi were blocked and moved upward along with phlegm and dampness and the stomach qi lost its ability to descend. The pulse was deep and thready in the chǐ, and wiry and choppy in the cùn and guān. The tongue had a thin and greasy coating. A book explained that “migratory bì syndrome is induced by wind, painful bì syndrome is induced by coldness, and localized bì syndrome is induced by dampness”. Obviously, the pain in this case was caused by cold and dampness. The previous diagnosis of liver qi invading the collaterals and blood failing to nurture the tendons were correct. However, the previous doctors didn’t think over the root of the disease. I modified Dú Huó Jì Shēng Tāng and Wú Zhū Yú Tāng (Evodia Decoction, 吴茱萸汤) to warm collaterals, drive out pathogens, purge the liver, and dissipate dampness. Five doses of dān shēn, fú líng, dāng guī, bái sháo, guì zhī, fáng fēng, dù zhòng, huái niú xī, zhì fù zĭ, xì xīn, bàn xià, wú zhū yú, dú huó, and sāng jì shēng was prescribed. The pain was greatly relieved and the nausea and vomiting stopped. Since there was no defecation for six days and the appetite was poor, I removed xì xīn and bàn xià and added shā rén 7 fen, bái zhú 0.5 qian, huáng qí 3 qian, and Bàn Liú Wán (Pinellia and Sulphur Pill) 1.5 qian to swallow with the previous prescription for another ten doses. After finishing the medicine, the patient recovered.1

Comments: Doctor Ding has grasped the root of the disease by analyzing the symptoms. Bì in this case was caused by cold and dampness sticking to the taiyang, shaoyin, and jueyin channels due to postpartum blood deficiency. It was accompanied by vomiting due to deficient cold. Therefore, Dú Huó Jì Shēng Tāng was prescribed to dispel wind-dampness, tonify the liver and kidney, and nourish qi and blood. The formula treats pathogenic qi and zheng qi simultaneously. This case has a similar pathogenesis to that of postpartum bì syndrome for which its pain can be treated by dispelling pathogens and reinforcing zheng qi. The spleen was deficient so the stomach qi counterflowed upward, induced by the stagnation of cold-dampness in the middle jiao. Therefore, modified Wú Zhū Yú Tāng was added to help bring an instant therapeutic effect. No defecation for six days was thought to be constipation due to deficient cold. Accordingly, Bàn Liú Wán was prescribed to warm the kidney and dispel cold, unblock yang, and direct the turbid downward. Aromatic shā rén was added to treat the poor appetite by dispelling dampness and waking up the spleen. Bái zhú was added to fortify the spleen and dispel dampness. Huáng qí was added to tonify qi in middle jiao. Then, with the blood vital and the qi enriched, this bì syndrome with both qi and blood deficiency was cured.

Summary Dampness removing formulas contains 19 major formulas and 19 associated formulas. They are divided into five categories:

● dampness-drying and stomach-harmonizing formulas 1 Ding Gan-ren. Medical Cases of Ding Gan-ren 丁⽢仁医案. Shanghai: Shanghai Scientific and Technical Publishers; 1960.

● heat-clearing and dampness-dispelling formulas

● urination-promoting and dampness-percolating formulas ● cold-damp warming and resolving formulas ● wind-dispelling and dampness-overcoming formulas 1. Dampness-drying and stomach-harmonizing formulas Píng Wèi Săn dries dampness, activates the spleen and moves qi to harmonize the stomach. It is the basic formula for dampness in the spleenstomach. Abdominal fullness and a thick, greasy tongue coating are the basic symptoms. Huò Xiāng Zhèng Qì Săn removes exterior wind-cold and dispels interior damp-turbidity, rectifies the spleen, harmonizes the stomach, raises the clear, and directs the turbid downward. It is the main formula used to treat cholera, vomiting, and diarrhea caused by exterior wind-cold and interior dampness. 2. Heat-clearing and dampness-dispelling formulas Yīn Chén Hāo Tāng reduces static heat, drains dampness, and removes jaundice to treat yellowed skin caused by damp-heat jaundice. Bā Zhèng Săn contains several heat reducing and urination promoting herbs. It is frequently used to treat damp-heat strangury. Both Sān Rén Tāng and Gān Lù Xiāo Dú Dān can be used to treat damp-warmth. Sān Rén Tāng is more effective to clear heat and is suitable at the early stage of damp-warmth when the pathogenic factor located at qi level and the dampness over heat syndrome. Gān Lù Xiāo Dú Dān is effective both in clearing heat and dispelling dampness. It is suitable for damp-warmth and seasonal plague when the pathogenic factor is located at the qi level and belongs to an excess dampheat pattern. Lián Pò Yĭn clears heat and dispels dampness and harmonizes the stomach to arrest vomiting. It is suitable for damp-heat cholera. Dāng Guī Niān Tòng Tāng clears heat, drains dampness, dispels wind, and relieves

pain. It is suitable for interior damp-heat, exterior wind, or wind and dampness that has transformed into heat leading to the onset of bì syndrome. Èr Miào Săn clears heat and dries dampness. It is the basic formula for atrophy caused by damp-heat pouring downward and eczema on lower part of the body. 3. Urination-promoting and dampness-percolating formulas Both Wŭ Líng Săn and Zhū Líng Tāng are commonly used formulas to promote urination and percolate dampness. Zé xiè, zhū líng and fú líng are the commonly used medicinals to treat urinary disturbance. Wŭ Líng Săn mainly treats excessive water-dampness and dysfunction of the bladder. It uses a combination of guì zhī and bái zhú to warm yang, transform qi, and promote urination. Zhū Líng Tāng mainly treats pathogens that have invaded the interior and transformed into heat, binding water and heat, and consuming yin fluid. Huá shí and ē jiāo promote urination, clear heat, and nourish yin. Fáng Jĭ Huáng Qí Tāng boosts qi to consolidate the exterior, dispels wind to move water, and primarily treats wind edema or wind-damp patterns. The symptoms are sweating, aversion to wind, urinary disturbance, a white tongue coating, and a floating pulse. Wŭ Pí Săn induces water and relieves swelling, rectifies qi and fortifies the spleen. It primarily treats swelling of the body, fullness and distention of the chest and abdomen, urinary disturbance, and skin edema. 4. Cold-damp warming and resolving formulas Líng Guì Zhú Gān Tāng warms the lung and dissolves rheum. It is the basic formula used to treat deficiency of the middle yang with retention of phlegm-rheum below the heart. Both Zhēn Wŭ Tāng and Shí Pí Săn primarily treat edema due to yang deficiency. They have the function of warming and supplementing the spleen and kidney, promoting urination, and

percolating dampness. Zhēn Wŭ Tāng uses fù zĭ as its chief medicinal, so it can warm the kidney, astringe yin, and relieve urgency. It mainly treats yang deficiency and edema with symptoms of abdominal pain and diarrhea, heavy limbs, and pain. Shí Pí Săn uses fù zĭ and gān jiāng as its chief medicinals, so it can warm the spleen, move qi and remove food stagnation. It mainly treats edema due to yang deficiency with fullness and distention of the chest and abdomen. Bì Xiè Fēn Qīng Yĭn warms the kidney and reduces dampness, raises the clear, and directs the turbid downward. It mainly treats turbid urine due to deficiency-cold. 5. Wind-dispelling and dampness-overcoming formulas Qiāng Huó Shèng Shī Tāng dispels wind and overcomes dampness. It is suitable for wind-dampnes in the exterior, body pain, and heavy limbs. Dú Huó Jì Shēng Tāng dispels wind-dampness and tonifies the body therefore, it is suitable for chronic bì syndrome, liver-kidney depletion, and qi and blood deficiency.

Questions 1.What are the different functions of huáng qí when it is used in the composition of Fáng Jĭ Huáng Qí Tāng, Dāng Guī Bŭ Xuè Tāng, Yù Píng Fēng Săn, and Bŭ Zhōng Yì Qì Tāng? 2.Wŭ Líng Săn, Wŭ Pí Săn, Zhēn Wŭ Tāng, and Shí Pí Săn are all used for edema. How do these formulas differ and how are they each applied? 3.Compare the similarities and differences between Qiāng Huó Shèng Shī Tāng and Jiŭ Wèi Qiāng Huó Tāng according to their medicinals, actions, and indications.

Endnotes: [1] 病痰饮者，当以温药和之

CHAPTER 15 Phlegm-Dispelling Formulas Phlegm-dispelling formulas use phlegm-dispelling medicinals as major components to remove the retention of phlegm and fluid to treat various phlegm diseases. They are closely related in function to the “dispersion method”, one of the eight treatment methods recorded in ancient literature. When body fluids fail to distribute in a normal manner, they will gather together and condense into phlegm. Phlegm is a pathologic product that may be involved in a variety of diseases. For instance, patients may present with cough when phlegm is in the lung, vomiting when in the stomach, dizziness when in the head, palpitations when in the heart, a cold sensation when in the back, and bloating when in the hypochondrium. The clinical manifestations attributed to phlegm are countless. As the sayings read “hundreds of diseases result from phlegm” [1] and “strange diseases mostly come from phlegm”[2]. The disease mechanism primarily involves the spleen, lung, and kidney. Various pathologic factors impair the zang-fu organs, especially the three organs responsible for the body’s water metabolism just mentioned. Thereby phlegm accumulates to cause diseases referred to as “phlegm disease”. Phlegm diseases can be divided into damp-phlegm, heat-phlegm, dryphlegm, cold-phlegm and wind-phlegm according to the disease’s nature. Therefore, formulas in this chapter are categorized into five types:

● formulas that dry dampness and dissolve phlegm ● formulas that clear heat and dissolve phlegm ● formulas that moisten dryness and dissolve phlegm ● formulas that warm and dissolve cold-phlegm ● formulas that extinguish wind and dissolve phlegm To treat phlegm disease, it is important to dissolve congealed phlegm. However, it is more important to remedy the source organs whose malfunctions are producing the phlegm. Zhang Jiebin once said:“one who is good at treating phlegm diseases emphasizes the prevention of phlegm production over removing the formed phlegm”[3]. That is the reason why phlegm-dispelling formulas are always combined with medicinals that fortify the spleen, dispel dampness, and boost the kidney. Since the disease mechanism is very complicated, the treatment varies according to the binding pathogens and the nature of the disease pattern. For example, phlegm diseases due to spleen deficiency should be treated by drying dampness, fortifying the spleen, and dissolving phlegm. Likewise, phlegm diseases caused by fire-heat that scorches the body fluid into phlegm should be treated by clearing heat and dissolving phlegm. Dry-phlegm disease should be treated by moistening the lung and dissolving phlegm. Coldphlegm disease results from cold-rheum retention and should be treated by warming and dissolving cold-phlegm. Wind-phlegm diseases should be treated by dissolving phlegm and extinguishing the wind. In terms of clinical application, one must accurately discern the source of the phlegm and clarify which pathogens (cold, heat, dry or dampness) are involved. Additionally, one must search out the source of phlegm production. Once the origin of phlegm production has been corrected, the disease will not relapse. Once phlegm forms, it moves as qi moves. It

accumulates where qi becomes stagnant and it automatically dissolves once qi moves smoothly. Therefore, phlegm-dispelling formulas are always combined with medicinals that rectify qi. Just like what Pang An-chang said: “a good way to treat phlegm disease is to rectify qi rather than resolving phlegm because the fluid circulation will become normal once the qi movement returns normal.” [4] Moreover, one should be cautious to use medicinals that are moistening and nourishing on patients with profuse phlegm accumulation pattern in case they may aggravate phlegm and hamper the disease from recovering.

Section 1 Formulas that Dry Dampness and Dissolve Phlegm These formulas are applicable to damp-phlegm patterns marked by profuse white phlegm that is easy to be expectorated, chest and gastric distention, nausea, vomiting, vertigo, physical fatigue, and palpitations. The tongue coating is glossy white or white and greasy. The pulse may be moderate or wiry and slippery. The therapeutic principle is to dry dampness and dissolve phlegm. Generally speaking, formulas in this section are mainly composed of medicinals that dry damp and dissolve phlegm, accompanied with medicinals that fortify the spleen, drain dampness, and rectify qi. Common medicinals that are found within this category include bàn xià, tián nán xīng, chén pí, fú líng, bái zhú, tài zĭ shēn, zhĭ shí, and hòu pò. The representative formula is Èr Chén Tāng.

Èr Chén Tāng ⼆陈汤Two Matured Substances Decoction

Source Text Beneficial Formulas from the Taiping Imperial Pharmacy (Tài Píng Huì Mín Hé Jì Jú Fāng, 太平惠民和剂局⽅)

Formula Ingredients

Preparation and Administration First add 7 pieces of shēng jiāng and 1 piece of wū méi into the decoction, then add in the other medicinals to decoct together. The decoction should be taken while it is warm.

Formula Indications Èr Chén Tāng is indicated for damp-phlegm patterns. The symptoms are cough with profuse white phlegm that is easy to be expectorated, nausea and vomiting, chest stuffiness, fatigue and heavy feelings of the body or limbs, vertigo and palpitations. The tongue coating is glossy white or white and greasy, and the pulse is slippery.

Analysis of Fundamental Pattern Pathogenesis When the spleen is attacked by pathogenic factors, it fails to transport and transform food and fluids, which leads to dampness or phlegm accumulation. When dampness or phlegm accumulates within the lung, it

becomes blocked and fails to disperse and descend normally. A cough with a lot of expectoration will result. When they accumulate in the stomach, nausea and vomiting occurs. When they accumulate in the chest and diaphragm to obstruct the normal qi movement, stuffiness or bloating occurs. When they lodge in the muscles, heaviness of the body or limbs occurs. When damp and phlegm obstruct the clear yang, vertigo occurs. When they attack the heart, palpitation occurs. In damp-phlegm diseases the tongue develops a glossy white or white and greasy tongue coating and the pulse becomes slippery. The treatment principle is to dry dampness and dissolve phlegm, rectify qi, and harmonize the center.

Formula Actions Dries dampness and dissolves phlegm, rectifies qi and harmonizes the center.

Formula Analysis

Unique Combination Features This formula mainly consists of medicinals that dry dampness and dissolve phlegm, accompanied by medicinals that rectify qi, fortify the spleen, and harmonize the center. It combines acrid medicinals that disperse qi with sour ones that astringe to treat both the root and the branch simultaneously. It is helpful to remove damp-phlegm and strengthen the spleen in order to prevent further phlegm production.

Further Clarification The name and indications of Èr Chén Tāng

Selecting aged bàn xià and jú hóng that have been stored for a long time, is preferable in order to avoid over-drying, which easily occurs when they are not aged. That is the reason for the name “Èr Chén” (two old medicinals). Although there are differences between cold-phlegm, heatphlegm, dryphlegm, damp-phlegm, wind-phlegm, qi-phlegm and foodphlegm, all of these phlegm disorders can be treated through appropriate modifications of Èr Chén Tāng. Thereby, Èr Chén Tāng is the “formula suitable to all phlegm disorders”.

Formula Applications 1. Essential pattern differentiation Èr Chén Tāng serves as a representative formula that is fundamental and commonly used to dry dampness and dissolve phlegm. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of damp-phlegm: chronic bronchitis, acute or chronic gastritis, Meniere’s syndrome, and psychogenic nervosa. 4. Cautions and contraindications The property of this formula is dry. Use it with caution for patients with dryness-phlegm. It is prohibited to use for patients who are spitting blood, suffering from wasting-thirst, are yin deficient, and are blood deficient.

Associated Formula Dăo Tán Tāng (Phlegm-Expelling Decoction, 导痰汤) [Source]

Formulas to Aid the living (Jì Shēng Fāng, 济⽣⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Dries dampness and removes phlegm, moves qi and opens constraint. [Applicable Patterns] Phlegm syncope pattern. Symptoms include: dizziness, accumulation of phlegm rheum, fullness of chest and diaphragm, distention of hypochondrium, headache and vomiting, panting and cough with expectoration, sticky snivel or saliva, a thick, greasy tongue coating, and a slippery pulse. Dí Tán Tāng (Phlegm-Flushing Decoction, 涤痰汤) [Source] Fine Formulas of Wonderful Efficacy (Qí Xiào Liáng Fāng, 奇效良⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction.

[Actions] Clears up phlegm and opens the orifices. [Applicable Patterns] Pattern of phlegm confounding the heart orifices caused by wind-strike. Symptoms include: distorted speech due to stiff tongue, wheezing of the throat, a white and greasy tongue coating, and a deep and slippery or deep and moderate pulse. Jīn Shuĭ Liù Jūn Jiān (Metal and Water Six Gentlemen Decoction , ⾦⽔六君煎) [Source] The Complete Works of [Zhang] Jing-yue (Jĭng Yuè Quán Shū, 景岳全 书) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Enriches and nourishes the lung and kidney, dispels dampness and dissolves phlegm. [Applicable Patterns] Lung and kidney deficiency complicated with excessive phlegmdampness accumulation. Symptoms include: cough, nausea and vomiting, panting with profuse phlegm, salty tasting phlegm or dry mouth and throat,

salty taste in the mouth, and a red tongue with a glossy white or thin greasy coating. Dăo Tán Tāng, Dí Tán Tāng and Jīn Shuĭ Liù Jūn Jiān are all modified from Èr Chén Tāng and share the same function to dry dampness and dissolve phlegm. Èr Chén Tāng minus wū méi and gān căo, plus tiān nán xīng and zhĭ shí makes Dăo Tán Tāng. Tiān nán xīng helps to promote the power of bàn xià to dry dampness and dissolve phlegm. Zhĭ shí enhances the function of jú hóng to regulate qi and dissolve phlegm. It’s stronger than Èr Chén Tāng to remove the damp-phlegm and is used to treat phlegm syncope syndrome caused by turbid phlegm obstruction and unsmooth qi movement. Dí Tán Tāng is composed of Dăo Tán Tāng plus shí chāng pú, zhú rú, rén shēn and gān căo, so it has the additional functions to open the orifices and reinforce zheng qi. Therefore, it is often used to treat wind-strike induced stiff tongue and blurred speech caused by phlegm confusing the heart orifice. Èr Chén Tāng minus wū méi, plus shú dì and dāng guī makes Jīn Shuĭ Liù Jūn Jiān. It is able to enrich yin and nourish blood, and simultaneously regulate the lung and kidney since the two can generate each other in terms of five-phase theory. Jīn Shuĭ Liù Jūn Jiān is applied to senior patients suffering from lung and kidney deficiency complicated with dampphlegm accumulation in the interior of the body.

Case Studies 1. Wind-strike Gu Jing, a 32-year-old man, had hemiplegia due to wind-strike with an arm that was locked into extension (opisthotonos). He was prescribed Èr Chén Tāng plus mài dōng 1 qian, bái sháo 1 qian, dāng guī 1 qian, tiān má 7 fen, qiāng huó 7 fen, huáng lián (stir-fried in ginger juice) 7 fen, huáng qín

7 fen, jīng jiè 5 fen and wū yào 5 fen to soothe the liver qi, nourish the liver blood, and clear away the liver fire. His condition resolved after he finished over ten doses.1 1 Xia Xiang. Classified Case Records of Famous Physicians-Vol. 1历代名医医案精选·卷⼀. Shanghai: Shanghai People’s Publishing House; 2004. p. 108-109.

Comments: Hemiplegia and opisthotonos are signs of wind-phlegm obstruction in the collaterals. In the prescription, Èr Chén Tāng was used to dissolve phlegm. Tiān má. Jīng jiè and qiāng huó were used to dispel wind and extinguish wind. Mài dōng and dāng guī were used to enrich yin, nourish blood and soften the sinews. Since it’s said in the classics that “all wind with shaking and vertigo is ascribed to the liver”, chuān xiōng and wū yào are used to soothe the liver and move qi and blood. Huáng lián and huáng qín were used to discharge heat and clear heat. 2. Phlegm stagnation An over-weight man, who is over 40 years old, used to over think so he now has internal phlegm and fire in the interior. One day, he felt an aversion to cold which was then followed by a feverish sensation, minor pain of the body, and vertigo as if the head could not endure the body weight. The fever was persistent so he self-prescribed Shēn Sū Yĭn to induce sweating, but it didn’t help. The doctor was then called. The pulse felt deep, surging and slippery, so the doctor determined that his condition was caused by an accumulation of phlegm-fire. Initially, he was prescribed with Èr Chén Tāng plus huáng lián, huáng qín, tiān má, shén qū, etc. In addition, Gŭn Tán Wán was given to purge. After several days, the fever was still there and the patient kept on coughing and spitting saliva. The doctor thought about what Zhu Dan-xi said, when the phlegm was located above the diaphragm, one must use method of vomiting instead of purgation. Therefore, Guā Dì Săn was applied this time to induce vomiting. The patient threw up about a half

bowl of phlegm. After that but he stopped taking this prescription for fear of the bitter taste. The fever was still there because the amount of phlegm that he threw up was too small. The doctor tried Rén Shēn Bái Hŭ Tāng and Wŭ Líng Săn, but that was not effective. The doctor thought that maybe the phlegm stagnation was too serious to be removed by vomiting or by draining methods, so he tried a prescription to dissipate constraint. The prescription included Èr Chén Tāng plus qián hú, chái hú, gé gēn, jié gĕng, cāng zhú, chuān xiōng, jiāng zhī, huáng qín, and zhī zĭ. After three doses, the symptoms were gone.1 Comments: In this case, the pathogenic mechanism was long-term phlegm-dampness accumulation that transformed into fire. Èr Chén Tāng was used to remove the phlegm. Huáng qín and zhī zĭ were added to clear heat or fire. Qián hú, chái hú and chuān xiōng assisted by regulating qi which helped to dispel the phlegm stagnation.

Wēn Dăn Tāng 温胆汤Gallbladder-Warming Decoction Source Text Treatise on Diseases, Patterns, and Formulas Related to the Unification of the Three Etiologies (Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn, 三因极⼀病证⽅论)

Formula Ingredients

1 Chen Meng-lei. Complete Records of Ancient and Modern Medical Works of the Grand Compendium of Books 古今图书集成·医部全录. Beijing: People's Medical Publishing House; 1991. p. 549.

Preparation and Administration Prepared as a decoction. It is best to take it while warm.

Formula Indications

Wēn Dăn Tāng is designed for patterns of gallbladder constraint with phlegm stirring up. This pattern manifests timidity and patients may be easily frightened. Other symptoms include vexation, insomnia or dreaminess, nausea, vomiting and hiccups, vertigo and epilepsy. The tongue coating is white and greasy, and the pulse is wiry and slippery.

Analysis of Fundamental Pattern Pathogenesis Constitutionally, these patients have gallbladder qi insufficiency, which is shown by their timidity or their tendency to be easily frightened. When they get depressed emotionally, the liver and gallbladder qi cannot flow freely. As a result, qi stagnation generates heat causing vexation, strange dreams at night, palpitations, and fluid accumulating into phlegm. When turbid phlegm harasses the interior, primarily the stomach, patients present with nausea, vomiting saliva or phlegm, and hiccups. When the phlegm blocks the clear orifices, patients may complain of vertigo, palpitations, or even epilepsy. Therefore, the treatment principle is to regulate qi and dissolve phlegm, harmonize the stomach and promote gallbladder secretion

Formula Actions Rectifies qi and dissolves phlegm, harmonizes the stomach and promotes gallbladder secretion.

Formula Analysis

Continued

Unique Combination Features This formula clears gallbladder and harmonizes the stomach, regulates qi, and dissolves phlegm. It treats not only the phlegm-dampness but also its source addressing the root and branch simultaneously. Through the application of this formula, adverse stomach qi can be directed downward, gallbladder constraint can be dispersed, and phlegmdampness can be dissolved. Once all the pathogenic factors are removed nothing can bother the gallbladder anymore, and all the symptoms will vanish.

Further clarification

The meaning of “Wēn Dăn” in the formula name It’s a controversial issue whether the name of the formula is truly Wēn Dăn Tāng (Gallbladder-Warming Decoction) or Qīng Dăn Tāng (Gallbladder-Clearing Decoction). This formula is first written in the Collection of Experienced Formulas (Jí Yàn Fāng, 集验⽅) by Yao Sengyuan. In which, the dosage of the warm-natured medicinals (shēng jiāng 4 liang, bàn xià 2 liang, jú hóng 3 liang and gān căo 1 liang, amounting to 10 liang all together) is much higher than that of the coldnatured medicinals (zhú rú 2 liang and zhĭ shí 2 pieces, about 2 liang, amounting to 4 liang). There’s a statement that says “this one can warm the gallbladder and treats disorders caused by gallbladder cold.” That is the reason why it is named “Wēn Dăn”. However, in Chen’s Wēn Dăn Tāng, the dosage of shēng jiāng is 4-5 pieces, so the warm property has been reduced a lot making it more of a cold nature relatively speaking. So the reason it could be named “gallbladder-clearing decoction” is due to the function. Chen’s formula originated from Yao’s, and in order to honor Yao for his contribution, the name remained the same even though the dosages were changed. The gallbladder governs decision. It is like a clear and quiet house that prefers calmness over vexation or harassment and mildness over congestion and constraint.Most of the formulas that treat the gallbladder are mildnatured. For example, Yao’s Wēn Dăn Tāng is composed of a large amount of shēng jiāng, which is warm but not dry, to warm the gallbladder. Chen’s Wēn Dăn Tāng clears the gallbladder by decreasing the dosage of shēng jiāng, which in turn gives more weight to the sweet, cool-natured zhú rú to work in accordance with the mild-natured gallbladder. (Vol.4 of Records of Thoughtful Differentiation of Materia Medica, Bĕn Căo Sī Biàn Lù, 本草思 辨录) Therefore, all formulas that treat the gallbladder should be consistent

with the gallbladder’s physiological character, which is that it prefers to be quiet rather than being disturbed (Vol. 2 of Investigations of Medical Formulas, Yī Fāng Kăo, 医⽅考) and all treatment should be primarily based on normalizing gallbladder qi.

Formula Applications 1. Essential pattern differentiation Wēn Dăn Tāng is a representative formula for gallbladder constraint with harassing phlegm. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient has a pattern of gallbladder constraint with rising

phlegm: acute or chronic gastritis, psychoneurosis, Meniere’s syndrome, menopausal syndrome, epilepsy, and acute or chronic bronchitis. 4. Cautions and contraindications It is applicable to the pattern of disharmony between the gallbladder and stomach, phlegmturbidity, and phlegm-heat harassing the interior. However, if the phlegm-heat is severe the power of the formula is not very strong and extra medicinals need to be added.

Associated Formulas Huáng Lián Wēn Dăn Tāng (Coptis Gallbladder-Warming Decoction, 黄连温胆汤) [Source] Systematic Differentiation of the Six Etiologies (Liù Yīn Tiáo Biàn, 六 因条辨) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and eliminates vexation, dries dampness and dissolves phlegm. [Applicable Patterns]

Trepidation and phlegm-heat harassing the interior. Symptoms include: insomnia, dizziness and tinnitus, vexation, nausea, bitter taste of the mouth, a pale tongue with a yellow, greasy coating, and a slippery and rapid pulse. Shí Wèi Wēn Dăn Tāng (Ten Ingredients Gallbladder-Warming Decoction, ⼗味温胆汤) [Source] Effective Formulas from Generations of Physicians (Shì Yī Dé Xiào Fāng, 世医得效⽅) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Boosts qi, and nourishes blood, dissolves phlegm and calms the mind. [Applicable Patterns] Pattern of trepidation and phlegm-turbidity harassing the interior. Symptoms include easy to be frightened, palpitation, insomnia, nightmares, shortness of breath and spontaneous sweating, dizziness and tinnitus, chest obstruction, restlessness, a pale tongue with a greasy coating, and a wiry and deficient pulse. Huáng Lián Wēn Dăn Tāng and Shí Wèi Wēn Dăn Tāng are both derived from Wēn Dăn Tāng. Huáng Lián Wēn Dăn Tāng is made up of Wēn Dăn Tāng and huáng lián. It is used to treat a Wēn Dăn Tāng pattern with

additional phlegm-heat. Shí Wèi Wēn Dăn Tāng consists of Wēn Dăn Tāng minus zhú rú, plus rén shēn, shú dì, wŭ wèi zĭ, suān zăo rén and yuăn zhì to boost qi and nourish blood, dissolve phlegm and calm the mind. It is applicable to patterns of heart and gallbladder deficiency with restlessness of the mind due to phlegm-turbidity harassing the interior.

Comparison & Contrast Èr Chén Tāng vs. Wēn Dăn Tāng

Case Studies Palpitation A 15-year-old female suffered from severe palpitations as if someone was going to arrest her; she even tried to escape but couldn’t find a shelter.

Her mother held her in her arms and the maids stood at her side to protect her, yet she was still too scared to fall asleep. Many doctors thought it was a heart disorder and prescribed Ān Shén Wán (Spirit-Calming Pill, 安神丸), Zhèn Xīn Wán (Heart-Sedating Pill, 镇⼼丸) and Sì Wù Tāng which turned out to be ineffective. Another doctor named Shi-shan thought it was disorder of the gallbladder after taking her pulse which he thought was thready, weak and moderate and Wēn Dăn Tāng was prescribed and it was effective.1 Comments: In Treatise on Diseases, Patterns, and Formulas Related to the Unification of the Three Etiologies (Sān Yīn Jí Yī Bìng Zhèng Fāng Lùn, 三因极⼀病证⽅论), Wēn Dăn Tāng was used to treat the pattern of “gallbladder cold” manifesting with “timidity and trepidation”. Although the formula was named after the functions “to warm the gallbladder”, its effect is to make people brave. In this case, the symptoms of palpitations and timidity were not caused by deficiency, but by disharmony between the gallbladder and stomach and phlegm-turbidity disturbing the mind causing palpitations and fear. Wēn Dăn Tāng was used to clear the gallbladder, harmonize the stomach, dissolve phlegm, and calm the spirit. The treatment matched the pathomechanism so the effect was sound.

Fú Líng Wán 茯苓丸Poria Pill a.k.a. Zhì Tán Fú Líng Wán (Phlegm-Treating Poria Pill, 治痰茯苓 丸) Source Text Selected Formulas from the Praiseworthy Studio, recorded in LifeSaving Formulas of Showing the Right Pathway (Shì Zhāi Băi Yī Xuăn Fāng: Quán Shēng Zhĭ Mí Fāng, 是斋百⼀选⽅: 全⽣指迷⽅)

Formula Ingredients

Preparation and Administration Grind the medicinals into powder and form into pills using jiāng zhī. Take 6 g each time with ginger soup or warm boiled water. It could also be taken as a decoction, mix the first three medicinals with ginger juice and then boil them together. Decoct normally, and then add air-slaked pò xiāo in until it dissolves.

Formula Indications 1 Xia Xiang, Wang Qing-qi. Selected Medical Cases of Famous Doctors in Different Periods: Shi-Shan’s Medical Cases 历代名医医案精选·⽯山医案. Shanghai: Shanghai People’s Publishing House; 2004. p. 98-99.

Fú Líng Wán is applicable to patterns of phlegm hidden in the middle jiao or lingering along the channels and collaterals. Clinical symptoms may involve aching pain or spasm of the arms, being unable to lift the arms, moving pain in the arms, numbness of the hands, and edema of the four limbs. The tongue coating is white and greasy, and the pulse is deep and thin or wiry and slippery.

Analysis of Fundamental Pattern Pathogenesis When the spleen gets deficient, it can’t transport and transform food into nutrients. Instead it becomes a pathogenic product, namely, phlegmdampness. When phlegm-dampness stays in the stomach and then spreads to the four limbs, disorders involving local numbness, aching or limited movement, spasms or edema are noticed. The tongue and pulse qualities indicate the presence of phlegmdampness. The treatment is to dry dampness and move qi, soften hard masses, and dissolve phlegm.

Formula Actions Dries dampness and moves qi, softens hard masses and dissolves phlegm.

Formula Analysis

Unique Combination Features This formula dissolves phlegm and moistens the intestines at the same time, so it can dissolve the phlegm in a manner that is not very obvious.

Formula Applications 1. Essential pattern differentiation: Fú Líng Wán is indicated for patterns of phlegm accumulation in the middle jiao, channels and collaterals. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of accumulation of obstinate phlegm: angioedema of upper limbs, chronic bronchitis, cervical spondylosis, and hyperplasia of prostate. 4. Cautions and contraindications This formula has a strong ability to dissolve phlegm through bowel laxation, so it’s not appropriate to prescribe for weak patients for long periods of time. It is not suitable to treat aching arms due to wind-damp accumulation.

Section 2 Formulas that Clear Heat and Dissolve Phlegm Formulas in this section are intended for heat-phlegm patterns. Key characteristics of pattern identification include cough with sticky, thick, yellow sputum which is very hard to expectorate, chest pain, dizziness and fright epilepsy caused by heat-phlegm. Heat-clearing and phlegmdissolving medicinals, such as guā lóu, bàn xià and zhú rú, are commonly used to treat heat-phlegm patterns. One can combine them with spleen-fortifying and dampness-draining medicinals, qimoving medicinals, and heat-clearing medicinals such as fú líng, bái zhú, chén pí, zhĭ qiào and huáng qín. Characteristic formulas are Qīng Qì Huà Tán Wán and Xiăo Xiàn Xiōng Tāng.

Qīng Qì Huà Tán Wán 清⽓化痰丸Qi-Clearing and Phlegm-Transforming Pill Source Text Investigations of Medical Formulas (Yī Fāng Kăo, 医⽅考)

Formula Ingredients

Preparation and Administration Grind the medicinals into powder and mix with jiāng zhī 100 g to form pills. Take 9 g each time, twice per day. Reduce the dosage accordingly when treating pediatric diseases. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratio.

Formula Indications Qīng Qì Huà Tán Wán is indicated for patients with cough caused by phlegm-heat. The symptoms include coughing and panting, expectoration of sticky, yellow sputum, obstruction of the chest and diaphragm, dyspnea, nausea and vomiting, and restlessness and agitation in severe cases. The tongue is red with a greasy and yellow coating and the pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis This formula is used to treat patients with qi stagnation due to phlegm obstruction, qi constraint transforming into fire, binding of phlegm, and heat obstructing the lung. The symptoms include coughing and panting, expectoration of sticky, yellow sputum, chest stuffiness, dyspnea, and nausea

and vomiting in severe cases. Phlegm-heat disturbing the heart and mind may cause restlessness, vexation, and agitation. The treatment principle is to clear heat and dissolve phlegm, rectify qi, and relieve cough.

Formula Actions Clears heat and dissolves phlegm, regulates qi, and relieves cough.

Formula Analysis

Unique Combination Features This formula simultaneously dissolves phlegm, clears heat, and regulates qi. When qi movement returns to normal, fire will be controlled.

Correspondingly, phlegm will also be controlled. Once this is accomplished the patient will completely recover.

Formula Applications 1. Essential pattern differentiation Qīng Qì Huà Tán Wán is a common formula applicable to cough with phlegm-heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of phlegm-heat accumulation: pneumonia, acute bronchitis and acute onset of chronic bronchitis. 4. Cautions and contraindications The formula is not appropriate for those patients suffering from dry cough due to yin deficiency and cold-phlegm caused by spleen deficiency because of its bitter and dry property.

Associated Formulas

Qīng Jīn Jiàng Huǒ Tāng (Metal-Clearing and Fire-Descending Decoction, 清⾦降⽕汤) [Source] Ancient and Modern Mirror of Medicine (Gŭ Jīn Yī Jiàn, 古今医鉴) [Ingredients]

[Preparation and Administration] Prepare it as a decoction with 3 pieces of shēng jiāng. [Actions] Clears the lung and subdues fire, dissolves phlegm and relieves cough. [Applicable Patterns] Cough due to heat-phlegm accumulation. Symptoms include: expectoration of yellow, sticky phlegm, thirst, vexation and stuffy chest, a red tongue with a yellow, greasy coating, and a slippery and rapid pulse. Both Qīng Qì Huà Tán Wán and Qīng Jīn Jiàng Huŏ Tāng are able to treat cough due to heatphlegm accumulation. Relatively speaking, the former is particularly suitable to treat expectoration of thick, yellow phlegm. The latter is more specific to treat the severe cough due to heat-phlegm accumulation. The former is stronger to clear qi and resolve phlegm with dăn nán xīng as the chief and zhĭ shí as the assistant. The latter adopts shí gāo to increase the function of purging fire, while at the same time, uses jié gĕng, bèi mŭ and qián hú to relieve cough.

Case Study Cough of the phlegm-heat pattern A 60-year-old man had his first visit on April 4th, 1989. The patient had contracted a cold due to the sudden change in the climate. Initially, he felt an aversion to cold and fever, headache and body pain, cough with profuse thin phlegm. He was treated with Western medicine in a hospital with limited effects. He still complained of fever, serious cough with yellow, sticky phlegm that was difficult to expectorate, fullness of the chest and diaphragm, thirst with a desire for drinking, constipation, and yellow urination. His tongue was red with a yellow, greasy tongue coating and his pulse was slippery and rapid. Chest fluoroscopy by X-ray showed thickened and messy lung markings and increased transparency indicating chronic bronchitis and emphysema. The pattern was differentiated as cough due to phlegm-heat obstruction. The treatment principle is to clear heat and dissolve phlegm, diffuse lung qi, and relieve cough. The prescription, a modified Qīng Qì Huà Tán Wán, included zhì bàn xià 10 g, dăn nán xīng 10 g, fú líng 12 g, chén pí 10 g, huáng qín 12 g, quán guā lóu 15 g, chăo zhĭ shí 10 g, zhì má huáng 6 g and zhì gān căo 6 g. Five doses of the formula was prescribed with instructions to decoct the medicinals in water and take one dose each day. His second visit was on April 9th. The phlegm-heat and coughing had been relieved gradually. His phlegm was now thick and white. And his thick, yellow and greasy tongue coating had been reduced. The former prescription, with the má huáng removed, was prescribed. After taking five doses, the cough was completely relieved. The patient still had a lot of phlegm, poor appetite, and fatigue. The tongue coating had turned white. At this time, the phlegm-heat was gone leaving turbid phlegm obstruction in the lung. Therefore, the treatment principle has changed to treat the root, the

spleen, in order to stop phlegm production. Liù Jūn Zĭ Tāng was prescribed this time to fortify the spleen, boost qi, and dissolve phlegm and the patient was then cured.1 Comments: In this case, the patient had latent phlegm-rheum that was induced and activated by an external wind-cold contraction. It had transformed into fire after a long term accumulation in the lung forming into the phlegm-heat pattern. The formula Qīng Qì Huà Tán Wán was used to clear heat and dissolve phlegm assisted with má huáng to diffuse the lung and relieve cough. It matched the patient’s condition and therefore proved to be effective.

Xiăo Xiàn Xiōng Tāng ⼩陷胸汤Minor ChestDraining Decoction Source Text Treatise on Cold Damage and Miscellaneous Diseases (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

1 Niu Yi-gui. Examples of Clinical Applications of Qīng Qì Huà Tán Wán清⽓化痰丸临床应⽤ 举隅. Journal of Guiyang College of Traditional Chinese Medicine. 1999; 21(3):33-34.

Preparation and Administration Decoct guā lóu with water in advance, and then add the other medicinals. It is best to take the formula while it is warm.

Formula Indications Xiăo Xiàn Xiōng Tāng is suitable for pattern of binding phlegm and heat. The symptoms are pĭ and oppression of the chest and abdomen, painful heart and chest distention, cough with sticky, thick and yellow sputum. The tongue is red with yellow and greasy coating. The pulse is slippery and rapid.

Analysis of Fundamental Pattern Pathogenesis

Mistreatment from using purgatives for exterior cold diseases leads to invasion of pathogenic heat binding with phlegm-turbidity which obstructs the epigastrium and causes minor chest bind disease. Phlegm-heat obstructs either the epigastrium or diaphragm and blocks qi so the patient may complain of pĭ and oppression of the stomach or chest. Phlegm-heat accumulates in the lung causing cough with sticky, thick and yellow sputum. The tongue and pulse qualities support the diagnosis of phlegm-heat accumulation. The treatment principle is to clear heat and dissolve phlegm, loosen the chest, and dissipate masses.

Formula Actions Clears heat and dissolves phlegm, loosens the chest, and dissipates masses.

Formula Analysis

Unique Combination Features Bitter-tasting huáng lián, acrid bàn xià, moistening guā lóu, and drying bàn xià are phlegmremoving medicinals with different properties that are

often used together to increase the ability to dissolve phlegm. Together, these three medicinals can eliminate masses caused by phlegm-heat.

Further Clarification Differentiation of the formula indications Xiăo Xiàn Xiōng Tāng is indicated to treat minor chest bind disease. Chest bind disease is caused by the mistreatment of exterior cold syndrome with purgatives causing the pathogens to penetrate into the interior. In Treatise on Cold Damage and Miscellaneous Diseases, there are three formulas that treat the chest bind disease. They are Dà Xiàn Xiōng Tāng, Dà Xiàn Xiōng Wán and Xiăo Xiàn Xiōng Tāng. The first one is used to treat the patterns of binding water and heat manifesting fullness with pain and tenderness from the epigastrium to the lesser abdomen. The second one is used to treat binding of water and heat in the upper part manifesting stiffness of the nape and the back. The third one is to treat binding of phlegm and heat manifesting as epigastric pain and tenderness. The three are different in terms of pathogens, disease location, and disease tendency.

Formula Applications 1. Essential pattern differentiation Xiăo Xiàn Xiōng Tāng serves as a common formula applicable to patterns of accumulation of phlegm and heat in the chest. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of binding of phlegm and heat in the epigastrium, chest and diaphragm: acute gastritis, cholecystitis, hepatitis, coronary heart disease, pulmonary heart disease, acute bronchitis, pleuritis, and adhesion of pleurae.

Associated Formula Chái Hú Xiàn Xiōng Tāng (Bupleurum Chest-Draining Decoction, 柴 胡陷胸汤) [Source] Revised Popular Guide to ‘Treatise on Cold Damage’ (Chóng Dìng Tōng Sú Shāng Hán Lùn, 重订通俗伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction.

[Actions] Harmonizes and clears heat, clears phlegm and loosens the chest. [Applicable Patterns] Pattern of inward invasion of the shaoyang channel, accumulation of phlegm and heat in the chest. Symptoms include: alternating chills and fever, fullness of chest and costal region, pain with tenderness, nausea and vomiting, poor appetite, bitter, sticky taste in the mouth, dizzy vision, cough with thick sticky phlegm, a yellow greasy tongue coating, and a slippery and rapid pulse. Chái Hú Xiàn Xiōng Tāng is mainly composed of Xiăo Chái Hú Tāng and Xiăo Xiàn Xiōng Tāng with some modifications. Remove the medicinals that reinforce zheng qi such as rén shēn, gān căo and dà zăo from Xiăo Chái Hú Tāng and add medicinals that clear heat, dissolve phlegm, and loosen the chest such as guā lóu, huáng lián, zhĭ shí and kŭ jié gĕng. This formula is able to harmonize the shaoyang channel, clear heat, clear phlegm, loosen the chest, and dissipate masses. It is applicable to the pattern of shaoyang chest bind which contains all shaoyang symptoms plus pĭ and fullness of the chest and diaphragm.

Case Studies Syncope due to roundworms Mr. Ma Di-an’s wife was treated for over-eating complicated with exposure to external windcold. She reported having a fever before dawn, dry lips, palpitations, and cold extremities after the treatment. Her pulses of both cùn part were slippery and rapid. It was diagnosed as a strange phlegm syndrome and was prescribed with Xiăo Xiàn Xiōng Tāng plus bái sháo yào,

lái fú zĭ, qián hú and huáng qín (processed with wine). After two doses, the next morning she discharged eight roundworms through bowel movements and she felt no more palpitations except for when fatigued. Her pulses became less slippery in the cùn while the chĭ became more palpable. This time she was prescribed Èr Chén Tāng plus bái zhú, bái sháo, and huáng qín (processed with wine) to regulate the body. She was cured after four doses of the above formula with added dāng guī.1 Comments: Phlegm-constraint and qi counterflow plus roundworms disturbing the interior were the cause of her syncope. In the prescription, Xiăo Xiàn Xiōng Tāng plus lái fú zĭ was used to dissolve phlegm and induce qi downward. Qián hú, bái sháo and huáng qín were used to clear heat, clear phlegm, lower qi, and direct turbidity downward. Bái sháo yào was used to calm roundworms because it has a sour flavor. Bitter tasting huáng qín and huáng lián were used to get rid of roundworms. After the roundworms were eliminated, the patient was deficient and fatigued, so one should reduce the strength of purgation. The prescription was changed from Xiăo Xiàn Xiōng Tāng to Èr Chén Tāng. Finally dāng guī was added to nourish blood and reinforce zheng qi, so the patient was cured.

Gŭn Tán Wán 滚痰丸Phlegm-Removing Pill a.k.a Méng Shí Gŭn Tán Wán (Chlorite PhlegmRemoving Pill, 礞⽯滚痰丸) Source Text Tai Ding’s Main Treatise on Health Cultivation recorded in Detailed Explanation of the Jade Pivot (Tài Dìng Yăng Shēng Zhŭ Lùn: Yù Jī Wēi Yì, 泰定养⽣主论: ⽟机微义) 1 Xia Xiang. Selected Famous Medical Cases in Different Periods, Sun Yi-kui’s Medical Works: Sun Yi-kui’s Medical Case. Vol.2 历代名医医案精选.孙⼀奎医学全书·孙氏医案·卷⼆. Shanghai: Shanghai People’s Publishing House; 2004. p. 129.

Formula Ingredients

Preparation and Administration Grind the above medicinals into a thin powder and then form into small pills using water. Take 8-9 g each time, once or twice a day with warm water.

Formula Indications Gŭn Tán Wán is used to treat patterns of excess heat and obstinate phlegm. Such patterns manifest many symptoms including mania and

palpitations due to fright, severe palpitations and fainting, coughing and panting while expectorating thick phlegm, vertigo and tinnitus, nodules around the neck, wriggling of the mouth and eyes, insomnia or strange dreams, sudden pain of the joints, vexation and stuffiness due to sighing and choking, and constipation. The tongue coating is yellow and thick and the pulse is slippery, rapid and powerful.

Analysis of Fundamental Pattern Pathogenesis Many strange or weird patterns are due to long term accumulation of excess heat and obstinate phlegm. When they obstruct the brain, mania and fainting occur. When they are harassing the heart-spirit, palpitations with or without fright, insomnia and strange dreaming occurs. When they accumulate in the lung, coughing with thick phlegm occurs. When they block the qi movement, fullness and oppression of chest and stomach occurs. When phlegm-fire stirs upward and clear yang fails to rise, vertigo and tinnitus occur. When fire and phlegm bind with each other in the intestines, constipation occurs. The tongue and pulse manifestation are signs of excess fire and obstinate phlegm. The treatment principle is to subdue fire and expel phlegm.

Formula Actions Drains heat and expels phlegm.

Formula Analysis

Unique Combination Features This formula contains both clearing and purgative methods. Concerned that the action of purgation may be limited, this formula applies heavy medicinals to direct qi downward in order to facilitate the elimination of phlegm-fire.

Formula Applications 1. Essential pattern differentiation Gŭn Tán Wán is a representative formula used for excess heat and obstinate phlegm. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is often used to treat wind-strike, schizophrenia, epilepsy, migraine, and neurosis caused by the pattern of excess fire binding with obstinate phlegm. 4. Cautions and contraindications This formula is not applicable to weak people or pregnant woman for fear that it may be too drastic and will impair the vital qi.

Case Studies Mania syndrome Ms Yuan, 47 years old, had her initial visit on June 14th, 1984. She had a history of mental illness that had been resolved for several years. Recently the disease relapsed because she had been thinking too much and suffering with mental depression. Her family members brought her to the doctor this time and said she was mentally insane. Her symptoms included occasional incoherent speech, namecalling, insomnia, vexing heat, headache, desire to go away, and constipation. Her tongue coating was thick and yellow. And her pulse was deep and excess. She had a dull affect and an indifferent expression. It was useless to take Western tranquilizer or sedatives. She had a pattern of phlegm and heat accumulation in the interior that was disturbing the spirit. The treatment principle was to discharge heat, and remove phlegm, and calm the heart-spirit. The prescription included méng shí (pounded) 25 g, dà huáng 10 g, huáng qín 15 g, chén xiāng 15 g, shēng dì 20 g, mài dōng 20 g, xuán shēn 20 g, and gān căo 10 g. She had her second visit on July 25th, 1984. After taking six doses of the above prescription, the patient began to defecate. At first, the stool was

hard and sticky with a bad smell. Then the color changed to brown and she defecated once a day. Her spirit improved. According to her family members her conscious was clear without confusion or name-calling. The vexing heat was alleviated and she could sleep for 3-4 hours without the help of Western medicine. Her tongue coating thinned and the pulse was deep and slippery. These indicate that the phlegm-heat was gradually being dissolved and the heart-spirit was calming down a little bit. The constipation came back after she finished taking the decoction so the doctor decided to prescribe Diān Kuáng Mèng Xīng Tāng plus dà huáng. The prescription included táo rén 30 g, xiāng fù 15 g, qīng pí 15 g, chái hú 15 g, bàn xià 15 g, mù tōng 15 g, chén pí 15 g, fù pí 15 g, chì sháo 15 g, sāng pí 15 g, sū zĭ 20 g, gān căo 15 g and dà huáng 7.5 g. Her third visit was on August 6th. During the last one and a half months the patient took twelve doses of the first and second prescription alternately and the disease came under control.1 Comments: Zhang Jing-yue once said:“ mania is mostly caused by heat induced by too much thinking or depression. The liver and gallbladder qi movement will constrain or counterflow. If it is constrained over a long period of time, it will transform into heat. The fire may then bind with qi or phlegm and lead to various symptoms.” This is consistent with this case. Gŭn Tán Wán was used to discharge heat, dissolve phlegm, and calm the spirit. Since the disease was caused by over-thinking and binding of constrained qi and blood, one must consider invigorating blood and regulating qi, once the phlegm-heat has been removed. That is why Diān Kuáng Mèng Xīng Tāng (Mania and Dream-Awakening Decoction, 癫狂梦 醒汤) created by Wang Qing-ren was adopted. The alternative use of Gŭn Tán Wán and Diān Kuáng Mèng Xīng Tāng is to prevent from relapse of phlegm-heat and consolidate the smooth flow of qi and blood.

Section 3 Formulas that Moisten Dryness and Dissolve Phlegm Formulas in this section are intended for patients with dryness-phlegm. The symptoms are thick, sticky sputum that is difficult to expectorate, dry throat, irritated cough, and hoarse voice. They are mainly composed of medicinals that moisten dryness and dissolve phlegm such as bèi mŭ and guā lóu and are often combined with spleen-enriching, dampness-draining, qimoving, phlegm-dissolving medicinals, and heat-clearing and yin-nourishing medicinals. The representative formula is Bèi Mŭ Guā Lóu Săn.

Bèi Mŭ Guā Lóu Săn 贝母瓜蒌散Fritillary Bulb and Snakegourd Fruit Powder Source Text Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟)

Formula Ingredients

1 Dong Jian-hua. Selected Medical Case of Modern Famous TCM Phycisian: Zhang Qi’s Medical Cases 中国现代名中医医案精华·张琪医案. Beijing: Beijing Publishing House; 1990. p. 2007-2008.

Preparation and Administration Decoct with water in the normal fashion.

Formula Indications Bèi Mŭ Guā Lóu Săn is intended for patients with coughing due to dryness-phlegm. The symptoms are cough, phlegm that is difficult to expectorate, and a dry throat. The tongue coating is white and dry.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by dryness-heat damaging the lung and consuming yin-fluids. Dry heat burns the lung fluids, forms dry-phlegm that blocks the lung qi and leads to cough. The dryness damages body fluids and is manifested as cough with phlegm that is difficult to cough out and a dry and painful throat. The white and dry tongue coating indicates drynessphlegm. The treatment is to moisten the lung and clear heat, rectify qi and dissolve phlegm.

Formula Actions Moistens the lung and clears heat, rectifies qi, and dissolves phlegm.

Formula Analysis

Unique Combination Features This formula combines the diffusing, moistening, dispersing and dissolving methods and harmonizes the lung and spleen simultaneously. It emphasizes moistening the lung and dissolving phlegm. It does so by moistening the lung without causing phlegm retention and dissolving phlegm without damaging the body fluids. In this way, the lung is cleared and moistened, the dryness-phlegm is dissolved, the lung qi normalized, and the problem resolved.

Formula Applications 1. Essential pattern differentiation Bèi Mŭ Guā Lóu Săn is a representative formula for phlegm-dryness. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula is often used to treat patterns of phlegm-dryness often seen in pulmonary tuberculosis, pneumonia, and so on. 4. Cautions and contraindications This formula is not applicable for coughing caused by lung-kidney yin deficiency and deficiencyfire flaming up.

Comparison & Contrast Bèi Mŭ Guā Lóu Săn vs. Sāng Xìng Tāng vs. Qīng Zào Jiù Fèi Tāng

Case Studies Cough A 3-year-old girl was sent to the doctor at the end of autumn in 1984. The chief complaint was aversion to cold and fever, cough with little phlegm, sore throat, and dry mouth. The tongue was light red with a peeled coating and the pulse was thready and rapid. She was given two bags of Sāng Xìng Tāng. After that, the external pattern was relieved, but she still coughed and it was difficult for her to expectorate phlegm. She was wheezing due to sputum in the throat. It was thought to be caused by phlegm and lung dryness, so the treatment principle was to moisten the lung and clear heat, dissolve phlegm, and relieve cough. Modified Bèi Mŭ Guā Lóu Săn was prescribed, including bèi mŭ 5 g, guā lóu pí 3 g, tiān huā fĕn 3 g, jié gĕng 3 g, běi shā shēn 5 g, mài dōng 5 g and yù zhú 5 g. After taking three doses, the patient recovered.1

Comments: The initial symptoms of aversion to cold and fever, cough with little phlegm, sore throat and dry mouth as well as the tongue and pulse manifestations were all signs of wind-heat invading the lung to cause a disorder of the lung qi movement. Therefore, two doses of Sāng Xìng Tāng were used to clear heat and diffuse the lung. After the first treatment, the chief symptoms changed to cough with difficulty to expectorate sputum indicating lung-dryness and phlegm accumulation. Modified Bèi Mŭ Guā Lóu Săn was used to moisten the lung, clear heat, dissolve phlegm, and relieve cough. In the formula, the chief medicinals, bèi mŭ and guā lóu, are important to clear phlegm-heat, moisten the lung, and relieve cough. Tiān huā fĕn, běi shā shēn, mài dōng and yù zhú were used to promote fluid production and nourish yin. Jié gĕng was used to diffuse the lung and soothe the throat and jú hóng to normalize qi and dissolve phlegm. After taking three doses, the patient completely recovered.

Section 4 Formulas that Warm and Dissolve Cold-Phlegm Formulas in this section are used to treat patterns of cold-phlegm. The symptoms and signs are cough with white phlegm, chest oppression, stomach stuffiness, labored breathing and wheezing, fear of cold, cold limbs, a white and greasy tongue coating, a wiry and slippery pulse or tight and slippery pulse. Core ingredients in this section are medicinals that warm and dissolve cold-phlegm such as gān jiāng and xì xīn. They are often combined with yang-warming, cough and panting-relieving, and digestion-promoting medicinals. Representative formulas are Líng Gān Wŭ Wèi Jiāng Xīn Tāng and Sān Zĭ Yăng Qīn Tāng.

Líng Gān Wŭ Wèi Jiāng Xīn Tāng 苓⽢五味姜⾟汤 Poria, Licorice, Schisandra, Dried Ginger, and Asarum Decoction Source Text Essentials from the Golden Cabinet (Jīn Guì Yào Lüè, ⾦匮要略) 1 Lian Jian-wei. Selected Famous Medical Cases from Different Periods 历代名⽅精编. Hangzhou: Zhejiang Science and Technology Publishing House; 1987. p. 524-525.

Formula Ingredients

Preparation and Administration Decoct with water and take while it is warm.

Formula Indications Líng Gān Wŭ Wèi Jiāng Xīn Tāng is indicated for coughing caused by a pattern of cold fluid-retention marked by coughing with a large amount of thin white sputum, a preference to spit out saliva, drooling, and a stuffy chest. The tongue coating is white and glossy and the pulse is wiry and slippery.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by spleen yang deficiency that generates internal cold and fluid retention. Deficient yang fails to transform dampness and as a result, pathogenic fluid retention forms. When it attacks the lung, the patient will cough. This is as the Spiritual Pivot-Pathogens (Líng Shū-Xié Qì Zàng Fŭ Bìng Xíng, 灵枢·邪⽓脏腑病形) described “the lung will be injured by (external or internal) cold and cold rheum accumulation.”[5] Cold fluid retention accumulates in the lung and prevents the lung from performing its normal function. The result is cough with a large amount of thin white sputum. Fluid retention blocks qi movement, leading to chest stuffiness. Pathogenic rheum invades the stomach which causes one to want to spit out rheum. The treatment is to warm yang and dissolve fluid retention.

Formula Actions Warms the lung and dissolves rheum.

Formula Analysis

Unique Combination Features This formula combines the warming and dispersing methods. It treats the root and branch, the lung and spleen, at the same time.

Formula Applications 1. Essential pattern differentiation Líng Gān Wŭ Wèi Jiāng Xīn Tāng is a commonly used representative formula for cough caused by cold rheum pattern. This clinical pattern is marked by:

● cough with a large amount of thin white sputum ● glossy white tongue coating

● wiry and slippery pulse 2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of interior cold fluid-retention: chronic bronchitis and emphysema. 4. Cautions and contraindications It is not applicable to patients with patterns such as heat and dryness in the lung, cough caused by yin deficiency, and blood-tinged sputum.

Associated Formulas Lěng Xiào Wán (Cold Wheezing Pill, 冷哮丸) [Source] Comprehensive Medicine According to Master Zhang (Zhāng Shì Yī Tōng, 张氏医通) [Ingredients]

[Preparation and Administration] Grind the medicinals into powder and make pills with jiāng zhī and shén qū. Take 6 g (3 g for weak patient) of powder with shēng jiāng decoction when asthma occurs. [Actions] Dissipates cold and clears phlegm. [Applicable Patterns] Cold phlegm labored breathing pattern. Symptoms include: labored breathing induced by cold attack on the back, cough, large amount of sputum, pĭ and fullness in the chest, and difficulty to lie on the back. Lěng Xiào Wán is used to treat the syndrome of exterior cold, interior cold, and phlegm that is pure excess. Má huáng and xì xīn are used to dissipate external cold. Chuān wū and shŭ jiāo are used to warm the interior. Yá zào and dăn nán xīng are used to dissolve solid phlegm. Bái fán and bàn xià are used to dry damp phlegm. The rest of the medicinals are used to smooth lung qi, relieve cough, and dissolve phlegm. The medicinals in the formula are drastic and are therefore not suitable for patients with weak constitutions. Lìng Gān Wŭ Wèi Jiāng Xīn Tāng is used to treat interior cold and damp-phlegm due to spleen yang deficiency. The pathomechanism is deficiency mixed with excess. Therefore, the treatment involves the lung and

spleen, which are the branch and root. Medicinals that warm the lung to disperse cold and resolve rheum are used to treat the branch, and medicinals that warm the spleen yang and resolve dampness are used to treat the root.

Sān Zĭ Yăng Qīn Tāng 三⼦养亲汤Three-Seed Filial Devotion Decoction Source Text Effective Formula recorded in Essentials of Expanded Miscellaneous Diseases (Jié Xiào Fāng: Zá Bìng Guăng Yào, 皆效⽅: 杂病广要)

Formula Ingredients

Preparation and Administration Slightly dry-fry the three medicinals and then pound them into pieces. Wrap it up in a cotton cloth and decoct mildly. Take the decoction frequently.

Formula Indications Sān Zĭ Yăng Qīn Tāng is applicable to patients with phlegm congestion, counterflow qi, and food stagnation. The symptoms include coughing with labored breathing, copious phlegm, chest obstruction, less food intake, difficulty with digestion. The tongue coating is white and greasy and the pulse is slippery.

Analysis of Fundamental Pattern Pathogenesis

Sān Zĭ Yăng Qīn Tāng is used to treat cough, counterflow qi and stuffiness due to phlegm obstruction in senior patients. When people get old, the center qi becomes deficient. It becomes hard to receive and transport food which leads to food stagnation and phlegm accumulation. Phlegm accumulates in the lung and stomach leading to the above-mentioned symptoms. The tongue and pulse characteristics indicate cold and phlegm obstruction. The therapeutic principle is to warm the lung and dissolve phlegm, direct qi downward, and promote digestion.

Formula Actions Directs qi downward and smoothes diaphragm, dissolves phlegm and promotes digestion.

Formula Analysis

Unique Combination Features The purpose of this combination is to dissolve phlegm, move qi, and promote digestion. Without medicinals that fortify the spleen, this formula is used to treat the branch only.

Further Clarification 1. The literal meaning of the formula name “Sān Zĭ Yăng Qīn Tāng” Sān Zĭ Yăng Qīn Tāng literally means “decoction made up of three kinds of medicinal seeds used to treat senile disease”. The three medicinals included in this formula all contain the word “zĭ” at the ending of their name which means both “seed” and “son”. They are used by sons to treat disorders of their parents or senile disease. 2. Status and actions of the medicinals in the formula There is no mention about the chief, assistant or envoy medicinals in this formula. Clinically, one should decide the proportion of the medicinals depending on the severity of phlegm congestion, counterflow qi, and food stagnation.

Formula Applications 1. Essential pattern differentiation Sān Zĭ Yăng Qīn Tāng is a common formula applicable to patterns of phlegm congestion, counterflow qi, and food stagnation. It is especially good for senior patients. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of phlegm accumulation, adverse flow of qi, and food stagnation: intractable cough, chronic bronchitis, bronchial asthma, and pulmonary heart disease. 4. Cautions and contraindications It is recorded in the original book that the three medicinals should be dry-fried slightly and then be smashed in order to reduce the stimulation to the larynx and throat and the lung and stomach. This is especially important for lái fú zĭ because its property will change to sink downward after being fried. When the medicinals are being smashed, the components can better dissolve out. In terms of administration, it is better to take the decoction frequently in small amounts each time, just like sipping tea.

Case Studies Asthma Mr. Liu, a 66-year-old retired worker, went to the outpatient department for treatment. His initial visit was on October 10th, 1994. His chief complaint was recurring cough and labored breathing for three years that has been active for the past month. Over the past three years, when there was an acute

onset of his condition, the patient felt it difficult to breath. The onset would last for several days and would then be relieved by anti-inflammatory and symptomatic treatment. The patient was hospitalized again this past September for a recurrent episode of asthma induced by a common cold. Physical examination observed extensive wheezing sounds bilaterally in lung area. Chest X-ray showed bilateral thickening lung markings in the lower lung. He was diagnosed with chronic asthmatic bronchitis complicated with pulmonary infection. After being treated with an intravenous drip of penicillin and amikacin and oral administration of aminophylline, salbutamol and so on for 10 days, his symptoms were relieved and he was discharged. However, he still complained of occasional cough, expectoration, and wheezing. He then went to Doctor Zhu for traditional Chinese medicine treatment. His symptoms included frequent coughing with a large amount of white sputum and obesity. He said that he had a wheezing sound in the throat, asthmatic breathing, and it was difficult to lie down on his back at night. He also reported chest and hypochondriac oppression and distention, dry mouth without a desire to drink, and dry stool. His lips and tongue were both dark. His tongue coating was yellow and greasy. His pulse was wiry and slippery. He was diagnosed with a pattern of external contraction of wind-cold complicating phlegm excess and constrained-heat of the liver and lung. The treatment principle was to dissolve phlegm and descend lung qi, dissipate cold and relieve labored breathing, calm the liver, and release spasm. He was prescribed a modification of Wŭ Zĭ Dìng Chuăn Tāng, Sān Ào Tāng and Xiāo Yáo Săn. The ingredients included sū zĭ 10 g, lái fú zĭ 10 g, bái jiè zĭ 3 g, tíng lì zĭ 10 g, xìng rén 10 g, zhì má huáng 3 g, zhì gān căo 6 g, huáng qín 10 g, chái hú 10 g, bò he 10 g, dāng guī 10 g, bái sháo 30 g, fú líng 10 g, and bái zhú 10 g. The patient was instructed to take one dose each day for

seven days. After seven doses, the cough and asthma gradually calmed and the amount of phlegm decreased. He was able to lie on his back and the defecation became free. However, he still complained of a dry mouth and little expectoration. His tongue was dark red with a white coating and his pulse was wiry and thready. So this time má huáng was removed and 10g of jié gĕng was added to the previous prescription. After taking another fourteen doses of the modified formula, the disease cleared. There was no relapse within two months of follow-up.1 1 Gao Xin-yan. Analysis of the Medical Cases from Famous Doctors through All Ages—Medical Cases from Dr Zhu Shenyu 古今名医医案赏析·祝谌予医案. Beijing: The People's Military Medical Press; 2003. p. 82-83.

Comments: The patient developed a cough with white sticky phlegm after a cold indicating the use of Sān Ào Tāng. Excessive whitish expectoration, wheezing sound of the throat, chest stuffiness, and the forced sitting position supported the diagnosis of turbid phlegm obstructing the lung. The corresponding formula was Wŭ Zĭ Dìng Chuăn Tāng (Sān Zĭ Yăng Qīn Tāng plus tíng lì zĭ and xìng rén). Fullness and distention of the chest and flank, dark lips, and the wiry, slippery pulse indicate liver and lung qi constraint for which the corresponding formula was Xiāo Yáo Săn. With all of the symptoms differentiated, the prescription was a combination of Wŭ Zĭ Dìng Chuăn Tāng, Sān Ào Tāng, and Xiāo Yáo Săn.

Section 5 Formulas that Dissolve Phlegm and Extinguish Wind Formulas that dissolve phlegm and extinguish wind are used for patterns of internal wind complicated with phlegm stirring up. The symptoms include dizziness and headache, epilepsy, syncope, and unconsciousness. Medicinals that diffuse and dissipate wind pathogens such as jīng jiè and phlegm-dissolving medicinals such as zĭ wăn and bái qián are always used for patterns of external wind with phlegm. For patterns of internal wind and phlegm stirring up, the treatment principle is to extinguish wind and dissolve phlegm. Accordingly, liver-calming and windextinguishing medicinals such as tiān má, and spleen-fortifying and phlegm-dissolving medicinals such as bàn xià, tiān nán xīng, and chén pí are always used together to treat the problem. One typical formula is Bàn Xià Bái Zhú Tiān Má Tāng.

Bàn Xià Bái Zhú Tiān Má Tāng 半夏⽩朮天麻汤 Pinellia, Atractylodes Macrocephala and Gastrodia Decoction Source Text Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟)

Formula Ingredients

Preparation and Administration Prepare as a decoction.

Formula Indications Bàn Xià Bái Zhú Tiān Má Tāng is designed to treat the pattern of windphlegm harassing the upper body. Symptoms include dizziness, headache, pĭ and oppression in the chest and diaphragm, nausea, and vomiting. The tongue coating is greasy and white. The pulse is wiry and slippery.

Analysis of Fundamental Pattern Pathogenesis Spleen deficiency easily leads to phlegm or damp production. Phlegmdampness may travel upward and harass the body along with internal liver wind causing various disorders. When it harasses the brain, headache and dizziness occur. When it blocks the middle jiao, disorders including chest and diaphragm pĭ and oppression, nausea and vomiting will appear. The white and greasy tongue coating indicates internal phlegm-turbidity. The wiry and slippery pulse indicates windphlegm. The treatment principle is to

dissolve phlegm wind and extinguish wind, reinforce the spleen and dispel dampness.

Formula Actions Dries dampness and dissolves phlegm, calms the liver and extinguishes wind.

Formula Analysis

Unique Combination Features

This formula treats wind and phlegm, the branch and root, at the same time. Its emphasis is primarily on dissolving phlegm and extinguishing wind, which is the branch. The role of strengthening the spleen and dispelling dampness is secondary.

Formula Applications 1. Essential pttern dfferentiation Bàn Xià Bái Zhú Tiān Má Tāng is a representative formula used to treat dizziness and headache caused by wind and phlegm. This clinical pattern is marked by:

● dizziness and headache ● white greasy tongue coating ● wiry slippery pulse 2. Modifications

3. Modern applications This formula is often used to treat patterns of wind-phlegm harassing the upper body such as aural vertigo, hypertension, neurological dizziness, seizures, and facial paralysis.

4. Cautions and cntraindications This formula is not appropriate for dizziness caused by yin deficiency and yang hyperactivity or insufficiency of qi and blood.

Case Studies Dizziness A middle-aged man suffered dizziness after a long bout of both sexual activity and alcohol indulgence for which he had since paid heavily for. There was hardly a day that he did not take medicinals. However, they did not help. When he went to the doctor, the doctor thought the pulse was deep and slippery indicating an upper (phlegm-fire) excess and lower (qi and blood) deficiency. Sexual indulgence consumed his essence resulting in kidney deficiency (yin deficiency with fire) and damp-phlegm obstructed the upper jiao. When the phlegm rose to the head following the pathological movement of deficiency heat, dizziness occurred. The treatment principle was to remove phlegm and subdue fire, and supplement deficiency. The prescription included bái zhú, fú líng, bàn xià, tiān má, jú huā, huáng băi, huáng qín, shān zhī and xuán fù huā.1 1 Xia Xiang. Application of Famous Formulas, Medical Cases Selected from Different Periods. Vol. 5. Dizziness历代名医医案精选· ⼤⽅医验⼤成· 卷之五· 眩晕. Shanghai: Shanghai People’s Publishing House; 2004. p. 192.

Comments: Too much alcohol consumption impairs the spleen and stomach and causes phlegm production. Sexual indulgence damages the lower jiao and leads to kidney deficiency fire. When the fire and phlegm bind together and move upward, dizziness occurs. In this formula, bái zhú and fú líng were used to fortify the spleen. Bàn xià and tiān má were used to dissolve phlegm and extinguish wind. Jú huā was used to calm the liver and extinguish wind. Huáng băi, huáng qín and shān zhī were used to clear heat

and drain fire. Xuán fù huā was used to descend qi downward and subdue fire.

Dìng Xián Wán 定痫丸Convulsion-Settling Pill Source Text Medical Revelations (Yī Xué Xīn Wù, 医学⼼悟)

Formula Ingredients

Preparation and Administration

Grind the above medicinals into thin powder and decoct them with 120 g of gān căo to make a paste. Add 100 ml of zhú lì and 50 ml of jiāng zhī to the paste and form pills. Take 9 g each time. It could also be prepared as a decoction. Decoct the former ingredients, except zhū shā and hŭ pò, with gān căo decoction, and then remove the dregs. Then add zhú lì, jiāng zhī, zhū shā, and hŭ pò into the mix to be taken together.

Formula Indications Dìng Xián Wán is applicable to epilepsy caused by wind-phlegm-heat accumulation. The clinical manifestation include a sudden onset of epilepsy, dizziness, falling to the ground, losing consciousness, anoopsia, vomiting white foam, wheezing sound in the throat, yelling, convulsion of the limbs, a whitish-yellow greasy tongue coating, and a wiry, slippery, and slightly rapid pulse. It can also be used to treat manic-depressive psychosis.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by an accumulation of wind-phlegm-heat that obstructs the brain orifice. When the patient has been frightened or angry for a long time, or experienced bad emotions to a great extent, the qi movement will be badly affected. As a result, the liver yang overacts to cause internal wind that stirs internal phlegm and binds with it to cause disease that manifests sudden seizures and unconsciousness. Eyes that are rolled up and spasms of the extremities indicate endogenous liver wind. Wheezing and foam-like drooling indicate excessive phlegm. The tongue and pulse characteristics indicate signs of wind-phlegm-heat. The treatment principle is to clear phlegm and extinguish wind, open the orifices and calm the mind.

Formula Actions Removes phlegm and extinguishes wind.

Formula Analysis

Unique Combination Features This is a good formula to treat epilepsy because it includes four methods in one prescription: clearing away heat and dissolving phlegm, calming the liver and extinguishing wind, wakening up the mind and opening the orifices, suppressing fright and calming the mind.

Formula Applications 1. Essential pattern dfferentiation It is commonly used for the treatment of epileptic seizures due to windphlegm-heat accumulation. This clinical pattern is marked by:

● whitish-yellow greasy tongue coating ● wiry, slippery, and rapid pulse 2. Modifications

3. Modern applications It is commonly applied for patients with epileptic seizures caused by wind-phlegm-heat accumulation. 4. Cautions and contraindications The formula places emphasis on treating the branch, so it is focused on removing phlegm and extinguishing wind to address emergency conditions. Once the seizures are relieved the treatment should also aim to resolve phlegm and extinguish wind. It should also tonify the primordial qi and reinforce zheng qi. At the same time, the patient should maintain a healthy diet and good mood in order to consolidate the effect.

Case Studies

Pediatric epilepsy A 3-year-old boy surnamed Hu was brought to the Chinese medicine doctor for repeating convulsions that were not related to fever. He had suffered with the convulsions for more than three months. On December 5th, 1989, the boy had a sudden seizure after a scream. The symptoms included clonic-convulsion of the extremities, facial spasm, and white foam secretion from the mouth. During the seizure his eyes would roll upward. The symptoms lasted for about one minute followed by relief. According to his parents, he has had approximately three grand mal seizures. He has also experienced tics of the eyelids or forehead that would occur every one to two minutes and last for about one minute. EEG testing verified epilepsy. The pulse was slippery and wiry and the tongue coating was white and greasy. His condition was diagnosed as wind-phlegm harassing the upper body and blocking the clear orifices. The treatment principle was to eliminate phlegm and extinguish wind. The prescription included tiān má 20 g, shí chāng pú 10 g, dăn nán xīng 10 g, quán xiē 5 g, bái sháo 15 g, suān zăo rén 12 g and gān căo 6 g. At his second visit, it was found that following 20 doses, the time of seizure onset decreased and the frequency of the eye tics dropped to once every thirty minutes. As the disease became steady, 1ml of Ginseng and Ophiopogon Injection (injection of Shēng Mài Săn) to be taken every day was added to reinforce zheng qi and dispel pathogens. By the third visit he had taken thirty doses of the formula. The little bit of seizure onsets and eye tics stopped and he behaved normally, so the Ginseng and Ophiopogon Injection was withdrawn. He continued to take the formula after being discharged from the hospital.

On his fourth visit, after taking the above formula for three months, he had another EEG. The results were normal. Thereafter, he stopped taking the medicinals and was normal within the oneyear follow-up since he stopped taking the formula.1 Comments: Pediatric epilepsy is mainly caused by wind-phlegm harassing the upper body and blocking the clear orifices. The treatment principle was to eliminate phlegm and extinguish wind. In this formula, shí chāng pú was used to ascend and disperse clear yang, dissolve dampness, dispel turbid phlegm, open the orifices, and awaken the mind. Dăn nán xīng was used to clear and dissolve turbid phlegm, extinguish wind, and suppress fright. Tiān má was used to calm the liver yang, extinguish internal wind, and relieve convulsions. Quán xiē was used to search out the wind pathogen to arrest convulsions. Bái sháo was used to inhibit liver yang, nourish blood, and astringe yin. Suān zăo rén was used to boost the heart and nourish the liver, and to relax the heart and calm the mind. Gān căo was used to harmonize the other ingredients. Based on the theory “long lasting disease leads to deficiency patterns”, Ginseng and Ophiopogon Injection was used to reinforce zheng qi, rescue from desertion, nourish yin, and engender fluids. It can strengthen the immune system to prevent recurrence of epilepsy.

Summary There are eleven formal formulas and eight associated formulas within the phlegm-dispelling formulas chapter. They are categorized as:

● formulas that dry dampness and dissolve phlegm ● formulas that clear heat and dissolve phlegm ● formulas that moisten dryness and dissolve phlegm ● formulas that warm and dissolve cold-phlegm

● formulas that extinguish wind and dissolve phlegm 1. Formulas that dry dampness and dissolve phlegm Èr Chén Tāng dries dampness and dissolves phlegm, rectifies qi and harmonizes the center, and is the basic formula to dissolve phlegm. It is indicated for cough with profuse white phlegm due to damp-phlegm obstruction. Wēn Dăn Tāng rectifies qi and dissolves phlegm, harmonizes the stomach and promotes gallbladder secretion. It is indicated for vexation, insomnia, nausea, vomiting, hiccup, and epilepsy caused by gallbladder constraint with harassing phlegm. Fú Líng Wán dries dampness and moves qi, softens hard masses and dissolves phlegm. It is indicated for aching pain, numbness of the hands, and edema of the four limbs caused by phlegm accumulation in the middle jiao. 2. Formulas that clear heat and dissolve phlegm 1 Bi Dao-cai, Zhang Xia. Application of Dìng Xián Wán in Treating Epilepsy 定痫丸加减治疗 ⼩⼉痫证. Hubei Journal of Traditional Chinese Medicine. 2000; 22 (8): 32-33.

Qīng Qì Huà Tán Wán clears heat and dissolves phlegm, regulates qi and relieves cough. It is indicated for coughing with yellow sticky phlegm due to phlegm-heat accumulation. Xiăo Xiàn Xiōng Tāng clears heat and dissolves phlegm, loosens the chest and dissipates masses. It is indicated for minor chest bind disease caused by binding of phlegm and heat in the epigastrium, chest and diaphragm. Gŭn Tán Wán drains heat and expels phlegm. It is indicated for palpitations due to fright, mania, severe palpitations, fainting, and many other strange or wierd symptoms caused by excess heat and obstinate phlegm. 3. Formulas that moisten dryness and dissolve phlegm

Bèi Mŭ Guā Lóu Săn moistens the lung and dissolves phlegm. It is indicated for thick, sticky sputum that is difficult to expectorate and dry throat caused by dryness-phlegm. 4. Formulas that warm and dissolve cold-phlegm Líng Gān Wŭ Wèi Jiāng Xīn Tāng warms the lung and dissolves rheum. It is indicated for coughing with a large amount of thin white sputum caused by cold fluid-retention. Sān Zĭ Yăng Qīn Tāng directs qi downward, smoothes diaphragm, dissolves phlegm and promotes digestion. It is indicated for cough with labored breathing, poor appetite, and poor digestion caused by phlegm congestion, qi counterflow, and food stagnation. 5. Formulas that extinguish wind and dissolve phlegm Bàn Xià Bái Zhú Tiān Má Tāng dries dampness and dissolves phlegm, calms the liver and extinguishes wind. It is indicated for dizziness, vomiting, phlegm syncope, and headache caused by wind-phlegm harassing the upper body. Dìng Xián Wán removes phlegm and extinguishes wind. It is indicated for epilepsy caused by wind-phlegm-heat accumulation

Questions 1.Why are the phlegm-dispelling formulas always combined with medicinals that fortify the spleen and rectify qi? 2.Compare the differences and similarities between Xiăo Qīng Lóng Tāng and Líng Gān Wŭ Wèi Jiāng Xīn Tāng in terms of formula actions and indications. 3.Explain the meaning of the formula name, “Wēn Dăn Tāng”. Explain its indications and combination features.

Endnotes: [1] 百病多因痰作祟 [2] 怪病多痰 [3] 善治痰者，惟能使之不⽣，⽅是补天之⼿ [4] 善治痰者，不治痰⽽治⽓，⽓顺则⼀身之津液亦随⽓⽽顺矣 [5] 形寒饮冷则伤肺

CHAPTER 16 DigestionPromoting Formulas Digestion-promoting formulas utilize digestion-promoting medicinals as key components. They have the therapeutic actions to promote digestion, fortify the spleen, remove accumulation, and remove stagnation. Digestionpromoting formulas are prescribed to treat food accumulation. The modern method “promote digestion” was historically referred to as the “dispersion method”. It is one of the Eight Treatment Methods recorded in ancient literature. The dispersion method is extensively applied for conditions of accumulation, stagnation and fullness that result from blockage of qi, blood, phlegm, dampness, food and worms. This chapter discusses the therapeutic method and formulas used for food accumulation. Related therapeutic methods and formulas are discussed in the qi-regulating, blood-rectifying, dampness-dispelling, accumulation-removing and worm-expelling chapters. The etiologies of food accumulation are essentially classified in terms of deficiency and excess. Deficient patterns of food accumulation are caused by spleen deficiency and poor digestion. Excessive patterns of food accumulation are due to an improper diet, bad dietary habits, and overeating. Digestion-promoting formulas are therefore categorized into two types:

● digestion-promoting and stagnation-removing formulas ● spleen-fortifying and digestion-promoting formulas

Formulas that promote digestion typically contain qi-regulating medicinals because internal accumulation inhibits qi movement. The opposite is also true; constraint and stagnation of the qi mechanism will induce obstruction. Therefore, removing accumulation is associated with moving the qi. Those who suffer chronic conditions with a deficiency of zheng qi, as well as spleen and stomach deficiencies require medicinals that reinforce zheng qi. They are used simultaneously along with those medicinals that disperse food accumulation. As a result of their pathological development, food accumulations may have either a hot or cold pathological character. Therefore these formulas may necessarily be heat clearing or warming in nature. It is not advised to take dispersing formulas for long periods of time. They are aggressive and may consume zheng qi, and are therefore contraindicated for patterns of deficiency without signs of excess.

Section 1 Digestion-Promoting and Stagnation-Removing Formulas Digestion-promoting and stagnation-removing formulas are used to treat food accumulation. The signs and symptoms include fullness and oppression of the chest and stomach cavity, belching, acid swallowing, aversion to food, nausea, vomiting, abdominal distention, abdominal pain and diarrhea. Common medicinals used to promote digestion are shān zhā, shén qū, lái fú zĭ and mài yá. Food accumulation may impede qi movement, produce dampness and constrain heat. Consequently, corresponding formulas often contain medicinals that regulate qi, remove dampness, and clear heat. When food accumulation and damp-heat obstruct the large

intestine and block the qi of the bowels, medicinals that drain downward may be used. Common formulas in this category are Băo Hé Wán and Zhĭ Shí Dăo Zhì Wán.

Băo Hé Wán 保和丸Harmony-Preserving Pill Source Text Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法)

Formula Ingredients

Preparation and Administration Grind the ingredients into powder and prepare into pills using water. One dose is approximately 6-9 g taken with warm water. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios.

Formula Indications

This formula is indicated for food accumulation in the stomach cavity. The symptoms are fullness, distending pain in the abdomen and stomach cavity, belching, acid swallowing, aversion to food, vomiting, and diarrhea. The tongue coating is thick and greasy, and the pulse is slippery.

Analysis of Fundamental Pattern Pathogenesis This is a pattern of food accumulation caused by an improper diet and overeating. Inhibition of the qi mechanism by food accumulation results in fullness and distending pain in the abdomen and stomach cavity. When the ascending and descending function of the spleen and stomach is impaired, diarrhea and vomiting may result. Diarrhea is caused by the clear yang failing to ascend and vomiting is due to turbid yin failing to descend. A thick, greasy tongue coating and a slippery pulse indicate food accumulation. The therapeutic principles used to remedy this pattern are to promote digestion and remove accumulation.

Formula Actions Promotes digestion and harmonizes the stomach.

Formula Analysis

Unique Combination Features This formula primarily promotes digestion; however, it also moves qi, removes dampness and clears heat.

Formula Applications 1. Essential pattern differentiation Băo Hé Wán is a commonly used formula applicable for a variety of food accumulation patterns. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of food accumulation: acute and chronic gastritis and enteritis, dyspepsia, and infants with diarrhea. 4. Cautions and contraindications: This formula is an aggressive formula that attacks and dispels; therefore, it should not be taken for long periods of time. Additionally, it should not be prescribed to treat food accumulation patterns due to spleen deficiency without proper modification.

Associated Formulas Dà Ān Wán (Greatly Calming Pill, ⼤安丸) [Source]

Teachings of [Zhu] Dan-xi (Dān Xī Xīn Fă, 丹溪⼼法) [Ingredients]

[Preparation and Administration] Grind the medicinals into powder and make pills with porridge. [Actions] Promotes digestion and fortifies the spleen. [Applicable Patterns] Food accumulation complicated by spleen deficiency. Symptoms include: indigestion, distending pain of the abdomen and stomach cavity, diarrhea, and infants with food stagnation. Dà Ān Wán is Băo Hé Wán plus bái zhú. The doses of the medicinals that compose Băo Hé Wán are all decreased and 2 liang of bái zhú is added. Dà Ān Wán is prescribed for cases of food accumulation with spleen deficiency. It has the action to promote digestion and fortify the spleen and is suitable for pediatric food accumulation.

Zhĭ Shí Dăo Zhì Wán 枳实导滞丸Immature Bitter Orange Stagnation-Moving Pill Source Text Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn, 内外伤辨惑论)

Formula Ingredients

Preparation and Administration Grind the medicinals into a fine power and prepare as pills using water. Take 6-9 g with warm water twice daily after meals. It can also be prepared as a decoction by adjusting the medicinal quantities based on the original ratios.

Formula Indications

Food accumulation with damp-heat, marked by distending pain of the abdomen and stomach cavity, diarrhea, constipation, dark scanty urine, a greasy yellow tongue coating, and a deep, forceful pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by an accumulation of both damp-heat and food. Food accumulation may induce damp-heat or there may be a pre-existing pattern of damp-heat that combines with food accumulation. When qi movement is blocked by internal stagnation, distension and pain of the abdomen and stomach cavity is the result. Damp-heat enters the large intestine to cause diarrhea. If heat obstructs qi movement there may be constipation. Dark urine, a greasy yellow tongue coating, and a deep and forceful pulse are all signs that indicate damp-heat. The therapeutic principle is to promote digestion, remove accumulation, clear heat and remove dampness.

Formula Actions Promotes digestion, removes stagnation, clears heat, and removes dampness.

Formula Analysis

Unique Combination Features In this formula two therapeutic methods are combined. The method of removing accumulation by draining downward is combined with the clearing method. Zhĭ Shí Dăo Zhì Wán emphasizes removing accumulation by draining downward, which is an application of the therapeutic principle “treating the flowing by promoting its flow”. It is used for diarrhea and dysentery caused by food accumulation with damp-heat.

Formula Applications 1. Essential pattern differentiation

Zhĭ Shí Dăo Zhì Wán serves as the most common formula applied for food accumulation with damp-heat blocking the stomach and intestine. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of food accumulation with dampheat: gastrointestinal dysfunction, bacillary dysentery, enteritis, and dyspepsia. 4. Cautions and contraindications This formula is prohibited for chronic dysentery and diarrhea with deficiency if there is no accumulation, and for pregnant women.

Associated Formulas Mù Xiāng Bīng Láng Wán (Costus Root and Areca Pill, ⽊⾹槟榔丸) [Source] Confucians’ Duties to Their Parents (Rú Mén Shì Qīn, 儒门事亲) [Ingredients]

[Preparation and Administration] Grind the medicinals into fine powder and make pills with water. Take 3-6 g with decoction of shēng jiāng or warm water after dinner twice per day. [Actions] Moves qi and removes stagnation, eliminates accumulation, and discharges heat. [Applicable Patterns] Food accumulation complicated by damp accumulation generating heat. Symptoms include: fullness, distention and pain in the abdomen and stomach cavity, red and white dysentery, tenesmus, constipation, a greasy yellow tongue coating, and a deep and excess pulse. Mù Xiāng Bīng Láng Wán and Zhĭ Shí Dăo Zhì Wán are both applicable for food accumulation with damp-heat. Mù Xiāng Bīng Láng Wán is more powerful at eliminating pathogens, but weaker at removing dampness, than Zhĭ Shí Dăo Zhì Wán.

Section 2 Spleen-Fortifying and Digestion-Promoting Formulas Spleen-fortifying and digestion-promoting formulas are used for food accumulation complicated by spleen and stomach deficiency. The signs and symptoms are fullness of the abdomen and stomach cavity, indigestion, tiredness, lack of strength and loose stool. These formulas combine common digestion-promoting medicinals such as shān zhā, shén qū, and mài yá, with qi-boosting and spleenfortifying medicinals such as rén shēn, bái zhú and shān yào. Common formulas in this category are Jiàn Pí Wán, Zhĭ Shí Xiāo Pĭ Wán and Gé Huā Jiě Chéng Tāng.

Jiàn Pí Wán 健脾丸Spleen-Fortifying Pill Source Text Standards for Diagnosis and Treatment (Zhèng Zhì Zhŭn Shéng, 证治 准绳)

Formula Ingredients

Preparation and Administration Grind the medicinals and prepare into pills using water. Take 6-9 g with warm water, twice daily. When prepared as a decoction, adjust the medicinal quantities based on the original ratios.

Formula Indications Food accumulation with spleen deficiency marked by indigestion, fullness and oppression of the abdomen and stomach cavity, loose stool, greasy yellow tongue coating, and a weak pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by food accumulation due to spleen and stomach deficiency. Spleen deficiency causes poor appetite and hinders

transformation and transportation. The result is indigestion and loose stool. An insufficient source of qi and limited blood production results in tiredness, lack of strength, and a weak pulse. As food accumulation blocks qi movement and generates damp-heat, fullness and oppression of the abdomen and stomach cavity and a greasy yellow tongue coating manifest. The therapeutic method is to fortify the spleen and harmonize the stomach, promote digestion and arrest diarrhea.

Formula Actions Fortifies the spleen and harmonizes the stomach, promotes digestion and arrests diarrhea.

Formula Analysis

Unique Combination Features This formula uses both attacking and supplementing therapeutic methods to achieve a balanced effect. It contains medicinals that supplement qi and fortify the spleen such as the four medicinals of Sì Jūn Zĭ Tāng and shān yào. It promotes digestion by fortifying the spleen and emphasizes supplementation. Therefore, medicinals that promote digestion are used to prevent the possible stagnation and qi consumption that may develop from the heavy use of supplementing medicinals. The formula has been named Jiàn Pí Wán because of the formula’s emphasis on fortifying the spleen to promote digestion.

Formula Applications 1. Essential pattern differentiation Jiàn Pí Wán serves as the most common formula applied for food accumulation due to spleen deficiency. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of food accumulation due to spleen deficiency: chronic enteritis and dyspepsia.

Associated Formulas Zhĭ Zhú Wán (Immature Bitter Orange and Atractylodes Macrocephala Pill, 枳术丸) [Source] Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn,内外伤辨惑论) [Ingredients]

[Preparation and Administration] Grind the medicinals into fine powder and prepare into pills using water. Take 6-9 g with decoction of hé yè or warm water twice per day. [Actions] Fortifies the spleen and disperses fullness. [Applicable Patterns] Food accumulation caused by spleen deficiency and qi stagnation. Symptoms include: fullness of the chest and abdomen and poor appetite. Jiàn Pí Wán and Zhĭ Zhú Wán both combine the attacking and supplementing therapeutic methods. The action to supplement the spleen and promote digestion of Jiàn Pí Wán is stronger than that of Zhĭ Zhú Wán. Jiàn Pí Wán additionally drains dampness, arrests diarrhea, and removes dampheat. It fortifies the spleen, promotes digestion and arrests diarrhea. Zhĭ Zhú Wán fortifies the spleen, removes accumulation and disperses fullness.

Case Studies

Constipation A female patient reported, as a chief complaint, constipation after delivery. She had a bowel movement only once every five to six days. Defecation was difficult and the stool was hard and dry. Before this visit, she had received plenty of treatment with no success. Her symptoms included a pale complexion that lacked luster, weak breathing, aversion from talking, mental fatigue, lack of strength, poor appetite, a pale tongue body with a white coating, and a thin, weak pulse. Jiàn Pí Wán was applied. The prescription was composed of dăng shēn 25 g, bái zhú 25 g, fú líng 20 g, shān yào 20 g, huáng qí 15 g, lái fú zĭ 15 g, chén pí 15 g, shā rén 15 g, mài yá 10 g, shén qū 10 g, shān zhā 10 g and gān căo 10 g. After ingesting three doses of the formula, all the symptoms were alleviated and the stool was soft. Jiàn Pí Wán was thereafter prescribed for a month. All of the symptoms were eliminated with no reoccurrences in the past four years.1 Comments: Women may suffer deficiency following delivery. Deficiency leads to the failure of the large intestine to conduct and transmit stool, resulting in constipation. Jiàn Pí Wán is characterized by the combination of medicinals that supplement and drain. It primarily supplements deficiency and fortifies the spleen to promote transformation and transportation. In this particular case the formula was dispensed as a decoction. Ròu dòu kòu was removed because it has a function to astringe the intestines, lái fú zĭ was used in place of mù xiāng, and huáng qí was added. Within the prescription, Sì Jūn Zĭ Tāng and huáng qí supplement the spleen to promote transformation and support the large intestine to conduct and transmit. Lái fú zĭ, chén pí and shā rén regulate qi and unblock stagnation to move qi and stool. In TCM, the soul of the treatment is to discover and properly diagnose the pathomechanism of the pattern, not the

symptoms. Therefore, in this case, the symptoms were alleviated after three doses and eliminated following another ten doses.

Zhĭ Shí Xiāo Pĭ Wán 枳实消痞丸Immature Bitter Orange and Glomus-Dispersing Pill a.k.a. Shī Xiào Wán (Sudden Smile Pill, 失笑丸) Source Text Secrets from the Orchid Chamber (Lán Shì Mì Cáng, 兰室秘藏)

Formula Ingredients

1 Lu Hong-yu, Liu Dian-feng. New Application of Jiàn Pí Wán健脾丸新⽤. New Journal of Traditional Chinese Medicine. 1992; 11: 44.

Preparation and Administration Grind the medicinals into a fine powder and prepare into pills with water. Take 6-9 g with warm water twice daily. It may also be prepared as a decoction for oral ingestion by adjusting the medicinal quantities based on the original ratios.

Formula Indications Spleen deficiency and qi stagnation with cold and heat combined, characterized by fullness below the heart, no desire to eat or drink, tiredness, lack of strength, difficult defecation, greasy, slight yellow tongue coating, and a wiry pulse.

Analysis of Fundamental Pattern Pathogenesis This pattern is caused by spleen and stomach deficiency, impaired ascending and descending of the spleen and stomach, combined cold and heat, qi obstruction, and dampness accumulation. Spleen deficiency results in a poor appetite with no desire to eat or drink. Tiredness and a lack of strength occur when qi and blood production is deficient and cannot supplement the body’s source of vitality. Food accumulation causes a failure to conduct and transmit and results in difficult defecation. Combined cold and heat complicated with qi stagnation results in fullness below the heart and a wiry pulse. A slight yellow and greasy tongue coating indicates the heat that is generated due to food accumulation blocking qi movement. Generally, it is a mixed pattern of excess and deficiency caused by spleen deficiency and qi stagnation complicated by combined cold and heat. Characteristically, this pattern exhibits more deficiency than excess and more heat than cold. The proper therapeutic method is to move qi in order to disperse fullness, fortify the spleen to supplement deficiency, and harmonize cold and heat.

Formula Actions Disperses and relieves fullness, fortifies the spleen and harmonizes the stomach.

Formula Analysis

Continued

Unique Combination Features

This formula is based on three formulas: Zhĭ Zhú Tāng, Bàn Xià Xiè Xīn Tāng and Sì Jūn Zĭ Tāng. It is characterized by the combined use of medicinals that have opposing natures. Zhĭ Shí Xiāo Pĭ Wán contains hot medicinals in combination with cold, acrid medicinals that open combined with bitter medicinals that descend, and medicinals that supplement combined with those that drain. Zhĭ shí and hòu pò are used in a large proportion, and huáng lián is prescribed at a higher dose than gān jiāng, thus, this formula removes more than it supplements and clears more than it warms. It is applied to patterns with more excess than deficiency and more heat than cold.

Formula Applications 1. Essential pattern differentiation Zhĭ Shí Xiāo Pĭ Wán serves as a common formula applicable to fullness below the heart caused by spleen deficiency with qi stagnation and combined cold and heat. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of spleen deficiency with qi stagnation and combined cold and heat: chronic gastritis, chronic bronchitis and gastrointestinal neurosis. 4. Cautions and contraindications This formula focuses on moving and dispersing, thus it should be used cautiously for cases of fullness in a pattern of more deficiency than excess.

Comparison & Contrast Zhĭ Shí Xiāo Pĭ Wán vs. Bàn Xià Xiè Xīn Tāng

Gé Huā Jiě Chéng Tāng 葛花解酲汤Flower of Kudzuvine Drunk-Relieving Decoction Source Text Clarifying Doubts about Damage from Internal and External Causes (Nèi Wài Shāng Biàn Huò Lùn, 内外伤辨惑论)

Formula Ingredients

Preparation and Administration

Grind the ingredients into a fine powder and mix together. Take 9 g as a draft with warm water. It may also be prepared as a decoction for oral ingestion using the medicinals in the original proportions. However, care should be taken to not overcook the formula as it contains aromatic medicinals.

Formula Indications This formula is indicated for spleen damage due to alcohol accumulation, marked by dizziness, vomiting, fullness and oppression of the chest and diaphragm, aversion to food, tiredness, dysuria, loose stool, a greasy tongue coating, and a slippery pulse.

Analysis of Fundamental Pattern Pathogenesis Gé Huā Jiě Chéng Tāng is formulated to treat spleen damage caused by excessive alcohol consumption. This pattern is characterized by damage to the middle jiao by alcohol accumulation that creates dampness and impairs the spleen and stomach. Alcohol has a hot, drastic nature, therefore, the dampness generates into damp-heat that easily disturbs the upper jiao and accumulates in the middle. There it impairs the ascending and descending functions of the spleen and stomach resulting in vomiting and diarrhea. Impaired spleen transformation and transportation may result in an aversion to food and tiredness. Qi stagnation due to dampness blockage results in fullness and oppression of chest and diaphragm, dysuria, greasy tongue coating and a slippery pulse. The dampheat in this pattern may also be referred to as alcohol-dampness. Alcohol-dampness is an invisible damp pathogen; therefore, the therapeutic methods necessary to remedy the pattern are:

● disperse and promote urination to separate and remove the invisible alcohol-dampness pathogenic accumulation

● regulate the qi and fortify the spleen Formula Actions Promotes urination and disperses to separate and remove the invisible alcohol-dampness pathogenic accumulation, regulates qi and fortifies the spleen.

Formula Analysis

Unique Combination Features Gé Huā Jiě Chéng Tāng is characterized by its ability to separate and remove the invisible alcohol-dampness pathogenic accumulation by combining the “induce sweating” therapeutic method with the “promote urination” method. Additionally, it combines medicinals that promote digestion and regulate qi, supplement qi and fortify the spleen, and those that regulate the zheng qi and pathogenic qi.

Formula Applications 1. Essential pattern differentiation Gé Huā Jiě Chéng Tāng serves as the common formula applicable to spleen damage caused by alcoholism. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be applied to the intoxicated and for alcoholism.

4. Cautions and contraindications It is inadvisable for long-term consumption because this formula may consume qi and damage the liquids.

Summary There are five formulas within the digestion-promoting formulas chapter. They are categorized as:

● digestion-promoting and stagnation-removing formulas ● spleen-fortifying and digestion-promoting formulas 1. Digestion-promoting and stagnation-removing formulas Băo Hé Wán is effective for promoting digestion and fortifying the spleen. It is the basic formula to promote digestion and remove stagnation. It is indicated for all types of food accumulation, stomach cavity fullness, abdominal distension, aversion to food, and belching. Zhĭ Shí Dăo Zhì Wán promotes digestion to remove stagnation, clears heat and removes dampness to expel damp-heat accumulation, and is indicated for food accumulation with damp-heat in the stomach and intestines. 2. Spleen-fortifying and digestion-promoting formulas Jiàn Pí Wán has a powerful action to fortify the spleen and promote digestion and to drain dampness and arrest diarrhea. It is characterized by its combination of supplementation and drainage. However, it is focused on supplementation. It is indicated for food accumulation due to deficiency of the spleen, manifesting in indigestion, fullness of the abdomen and stomach cavity, and loose stool. Zhĭ Shí Xiāo Pĭ Wán has the action to disperse and remove fullness, fortify the spleen and harmonize the stomach. It is a formula that combines supplementation and drainage; however, it is focused

on drainage. It is indicated for a combined deficiency and excess, combined cold and heat, qi obstruction and dampness accumulation marked by fullness below the heart and aversion to food. Gé Huā Jiě Chéng Tāng is used to promote urination and disperse in order to separate and remove the invisible alcohol-dampness pathogenic accumulation, regulate qi and fortify the spleen. It is indicated for spleen damage caused by alcoholism, marked by dizziness, vomiting, fullness and oppression of the chest and diaphragm, aversion to food, tiredness, and dysuria.

Questions 1.Băo Hé Wán is a formula used to promote digestion and harmonize the stomach, why does it include lián qiào? 2.How can we explain the therapeutic method of treating the flowing by promoting its flow in Zhĭ Shí Dăo Zhì Wán? 3.Jiàn Pí Wán and Zhĭ Shí Xiāo Pĭ Wán both are formulas that combine supplementation and drainage. How do these two formulas differ and how can they be applied? 4.Why does Gé Huā Jiě Chéng Tāng have the effect to disperse and promote urination and to separate and remove the invisible alcohol-damp pathogenic accumulation? What are the points of caution to follow when administering this formula?

CHAPTER 17 Worm-Expelling Formulas Worm-expelling formulas contain roundworm-calming and wormexpelling medicinals as key components. They are used to treat worm infestations within the digestive tract. Although there are many species of parasites that may infest the digestive tract, this chapter will describe the treatment of roundworm infestation and the representative formula most commonly used to treat it. The eggs of roundworms enter the body through contaminated food. Roundworm infestation is therefore a disease related to unsanitary food conditions. When roundworms have infested the digestive tract, sporadic pain of the abdomen and the navel will occur. The pain causes a loss of appetite. When the pain subsides, the appetite will return. Other common signs and symptoms of roundworm infestation include a sallow complexion or a complexion that is pale with red lips, a white spot similar to dry moss located on the face, teeth grinding during sleep, upset stomach, clear vomit, peeling of the tongue coating, and a pulse that alternates between big and small. An untreated, or unsuccessfully treated, persistent infestation is characterized by emaciation, poor appetite, sluggishness, poor eyesight and dim vision, dry and withered hair, swollen belly, and vein distension. Left untreated it will eventually develop into a pattern of malnutrition and accumulation. Other symptoms of roundworm infestation are itchy ears and nose, cravings for particular foods or substances, and blue-grey patches

located on the whites of the eyes. If the roundworms penetrate the bile duct, the host will develop syncope along with specific correlative symptoms such as vomiting of roundworms, intermittent drilling pain in the right upper abdomen, and cold limbs. The purgative, dispersing, and harmonizing methods are used together within worm-expelling formulas. Because roundworms infest the lumen of the intestines, purgative and dispersing methods are used to kill and disperse the worms as well as to eliminate accumulation. Some Chinese medicinals such as bīng láng and shĭ jūn zĭ have the function to expel worms and purge. When roundworms become restless because of cold and heat in complexity, the harmonizing method should be applied in order to calm the worms and facilitate worm expulsion. Cold and hot medicinals are used together to harmonize in a fashion that is similar to how they are used within the harmonizing formulas that regulate the stomach and intestines. The formulas in this chapter are composed of roundworm-calming medicinals such as wū méi and worm-expelling medicinals such as chuān jiāo, shĭ jūn zĭ and bīng láng. The representative formula is Wū Méi Wán. Worm-expelling formulas should be taken on an empty stomach, especially before bed. Greasy, oily foods and sweets should be avoided. In some circumstances, purgative medicinals are needed to discharge the worms. However, when medicinals that have a relaxing action such as bīng láng and shĭ jūn zĭ are used, it may not be necessary to add purgatives. To verify that worms have been expelled, one must examine the stool. The spleen and stomach should be regulated and supplemented in order to improve nutritional intake and avoid damage to the zheng qi. Expelling worms without fortifying the spleen may leave the zheng qi damaged after the worms have been expelled and possibly can lead to other pathology. For patients with spleen and stomach deficiency, fortifying the spleen is a

priority. In addition, one should pay attention to their hygiene and diet in order to avoid re-infection. The stool should be re-examined after a certain period of time to check for infestation. If there is infection, the treatment can be applied again as necessary. When prescribing worm-expelling formulas, one should modify the prescription to include medicinals that will properly address the patient’s condition in terms of the diagnostic patterns ascertained such as cold and heat and deficiency and excess. One may prescribe heat-clearing medicinals such as huáng lián and huáng băi, interior-warming medicinals such as gān jiāng and fù zĭ, dispersing medicinals such as shén qū and mài yá, or supplementing medicinals such as rén shēn and dāng guī. Worm-expelling medicinals need to be prescribed cautiously. They are invasive and toxic and therefore may not be applicable for elderly, weak or pregnant patients. When composing a prescription, the dose should be carefully considered because if the dose is too low, the formula might not be able to effectively expel the worms. However, if the formula’s dose is too high, then it can damage the zheng qi and possibly cause toxic poisoning. Once the worms have been expelled, the formula should be discontinued.

Wū Méi Wán 乌梅丸Mume Pill Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formulas Ingredients

Preparation and Administration Steep the wū méi in vinegar overnight. After steeping, remove the kernel and mash it up. Mix all of the ingredients together and dry them. Once dry, grind the mixture into powder and make pills with honey. Take one 9 g dose two or three times daily on an empty stomach with warm water.

Formulas Indications Wū Méi Wán is used for syncope due to roundworms. The symptoms include paroxysmal pain of the abdomen and stomach cavity, vexatious vomiting, vomiting after eating, vomiting roundworms, cold limbs, and chronic diarrhea or dysentery.

Analysis of Fundamental Pattern Pathogenesis The pattern of syncope due to roundworms that Wū Méi Wán treats is caused by a complicated condition referred to as cold and heat in complexity. When there is deficiency cold in the intestines, roundworms

become restless and begin to migrate upwards in search of warmth. Roundworms prefer warmth and have an aversion to cold; hence the saying, “roundworms are restless with cold and relaxed with warmth.” They live in the intestines, drill into tissues and harass the upper body. Therefore, cold and heat in complexity may cause roundworms to become restless and lead to paroxysmal pain in the abdomen and stomach cavity, vexatious vomiting and vomiting of roundworms. The pain is intermittent because symptoms appear when the roundworms become restless and disappear when they are relaxed. Severe pain typically results in counterflow and disordered qi movement leading to poor communication between the yang and yin, cold hands and syncope. The cold and heat in complexity and deficiency of zheng qi also leads to chronic diarrhea and dysentery.

Formula Actions Calms roundworms and relieves pain.

Formulas Analysis

Unique Combination Features One unique feature of Wū Méi Wán is that it combines sour, acrid and bitter medicinals together. Roundworms are calmed with sour, subdued with acridity and purged with bitter. Other unique features include the simultaneous use of cold and hot medicinals and the regulation of both zheng qi and pathogenic qi.

Further Clarification Why can Wū Méi Wán be applied to chronic diarrhea and dysentery? This is because chronic diarrhea and dysentery are both generally caused by a condition of cold and heat in complexity that occurs as pathogens and turbidity accumulate due to deficiency cold of the spleen and stomach, deficiency of qi and blood, and incontinence of the intestines. Wū Méi Wán

has a sour flavor and an astringent property, which thereby astringe the intestines. It also warms the yang, supplements deficiency, clears heat and dries dampness. Comprehensively, the formula properly addresses the mechanism of this pathology.

Formula Applications 1. Essential pattern differentiation Wū Méi Wán serves as both a common and representative formula applicable for syncope due to roundworms and the condition of cold and heat in complexity. This clinical pattern is marked by:

2. Modifications

3. Modern applications This formula may be used in the following biomedically defined disorders when the patient shows signs of cold and heat in complexity and deficiency of qi and blood: biliary ascariasis, intestinal ascariasis, chronic bacillary dysentery, chronic gastroenteritis, and colitis. 4. Cautions and contraindications

This formula should be applied for excessive cold patterns because it is predominantly warm. Avoid raw, cold and malodorous food during the course of treatment.

Associated Formulas Lĭ Zhōng Ān Huí Tāng (Center-Regulating and Ascaris-Calming Decoction, 理中安蛔汤) [Source] Categorized Patterns with Clear-cut Treatments (Lèi Zhèng Zhì Cái,类 证治裁) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Warms the center and calms roundworms. [Applicable Patterns] Yang qi deficiency of the middle jiao, abdominal pain due to roundworms. Lián Méi Ān Huí Tāng (Picrorhiza and Mume Ascaris-Calming Decoction, 连梅安蛔汤) [Source]

Popular Guide to the ‘Treatise on Cold Damage’ (Tōng Sú Shāng Hán Lùn, 通俗伤寒论) [Ingredients]

[Preparation and Administration] Prepare it as a decoction. [Actions] Clears heat and calms roundworms. [Applicable Patterns] Heat constraint of the liver and stomach, abdominal pain due to roundworm accumulation. Wū Méi Wán, Lĭ Zhōng Ān Huí Tāng and Lián Méi Ān Huí Tāng are formulas that calm roundworms and expel worms. They are all indicated for ascariasis yet vary because they address different pathomechanisms. Wū Méi Wán is applied for severe syncope due to roundworms with cold and heat in complexity. It combines bitter, acrid and sour medicinals, regulates cold and heat, and regulates pathogenic qi and zheng qi. It primarily warms the intestines and stomach and secondarily clears heat constraint to calm roundworms. Lĭ Zhōng Ān Huí Tāng is made up of Lĭ Zhōng Tāng with gān căo removed, add fú líng to fortify spleen and remove dampness, chuān jiāo to warm the center and dispel cold, and wū méi to calm roundworms. Therefore, it is used to treat abdominal pain due to deficiencycold of the middle jiao induced by roundworm infestation. Lián Méi Ān Huí Tāng is indicated for syncope due to roundworms caused by excessive heat of the

liver and stomach. It also combines bitter, acrid and sour medicinals to clear and descend liver and stomach heat and expel roundworms.

Case Studies 1. Syncope due to roundworms Li, a 33-year-old female. Initial visit: July 16th, 1971. The patient began having pain in the upper abdomen five days prior to her visit. The pain was accompanied with a body temperature of 37.5°C, reversal cold of the hands and feet and no desire to eat or drink. When the pain was severe, she would vomit yellow, bitter fluid. Signs included a facial white spot, a greasy and white tongue coating, and a wiry, rapid pulse. She was diagnosed with biliary ascariasis and presented with a pattern of syncope due to roundworms caused by cold and heat in complexity, which led to roundworm accumulation in the biliary duct. The therapeutic method used was to calm roundworms and expel worms, harmonize the center and direct counterflow downward. Two doses of wū méi 10 g, hú huáng lián 10 g, wú zhū yú 3 g, dà huáng (unprepared) 6 g, guì zhī 5 g, shŭ jiāo 5 g, chuān liàn zĭ 15 g, bīng láng 15 g, jiāng bàn xià 10 g and shēng jiāng 6 g were prescribed. She came for her second visit on July 18th and reported that she felt severe pain after taking the formula on an empty stomach and expelled two dozen roundworms. After the vomiting stopped, the pain was significantly relieved and the warmth returned to her limbs. She then drank rice gruel. Her body temperature was measured at 36.8°C. She was prescribed the same formula with the following modifications: dà huáng and shēng jiāng were removed and the dosages of chuān liàn zĭ and bīng láng were decreased. The modified formula contained wū méi 10 g, hú huáng lián 10 g, wú zhū yú 3 g, guì zhī 5 g, shŭ jiāo 5 g, chuān liàn zĭ 10 g, bīng láng 10 g and jiāng bàn xià

10 g. After taking two doses, the pain was relieved and the patient’s appetite improved. She was thereafter discharged from hospital.1 Comments: This patient was hospitalized because of acute abdominal pain. According to the symptomatology, pulse diagnosis, and other associated examinations, she was properly diagnosed with biliary ascariasis. According to TCM, she suffered syncope due to roundworms and therefore the application of Wū Méi Wán was appropriate. Wū Méi Wán is from the Treatise on Cold Damage and is effective for vomiting roundworms in a jueyin disease conformation. Its clinical applications are broad; however, it must be modified according to the presenting symptoms. For example, rén shēn, dāng guī, and fù zĭ should be removed when the patient is neither significantly deficient nor with cold limbs. Wū méi is the primary medicinal to both calm roundworms and expel worms. However, it must be combined with bīng láng and dà huáng to enhance its power to expel worms and discharge roundworms from the stool. In this case, the patient discharged two dozen roundworms after ingesting two doses of Wū Méi Wán that was properly modified according to the symptomatology. It is clearly evident that Wū Méi Wán has a particular therapeutic effect on biliary ascariasis. 2. Chronic diarrhea and amenorrhea Zhao, a 23-year-old female. She had suffered loose stool since 1951. Although she had taken a variety of prescriptive drugs and Chinese medicinals, she had no recovery. Since the winter of 1961, she began to have frequent diarrhea, especially at night. Currently she was experiencing two or three episodes of diarrhea in the day and one or two during the night. Before defecation, she suffered borborygmus, abdominal distention, and flatulence. Then she would have a sudden, uncontrollable urge to defecate. After evacuation, the abdominal

discomfort was alleviated. Other symptoms included sweating, feverish sensation in the palms, dry mouth with thirst, poor appetite, weakness in the waist, heaviness of the lower limbs, a preference for warmth on the lower back, and amenorrhea. She had a deep, thin pulse and a pale tongue with a white, greasy and wet coating. She was diagnosed with kidney deficiency due to chronic diarrhea, cold-damp accumulation, and constrained heat. A modification of Wū Méi Wán was prescribed for this case of chronic diarrhea because Wū Méi Wán combines acrid, bitter, sweet, and sour medicinals. The medicinals include dăng shēn 10 g, ròu guì 5 g, huáng lián 3 g, mù xiāng 5 g, shŭ jiāo 3 g, dāng guī 9 g, bái sháo 9 g, zhì gān căo 5 g and Sì Shén Wán (wrapped) 18 g. After taking four doses, the abdominal pain was slightly relieved without any other improvements. It was decided that the cold-dampness accumulated in the lower jiao needed to be removed as the priority. This decision was based on the white, greasy and wet tongue coating. Therefore bái sháo and Sì Shén Wán were removed and cāng zhú, wū yào, ròu dòu kòu, and páo jiāng was added. After taking four doses of the adjusted formula, the abdominal pain was markedly relieved, there was less flatulence, and no more episodes of diarrhea at night. The tongue coat thinned and a dark menstrual blood began to flow lightly. The formula was once again modified by adding xiăo huí xiāng to warm the kidney qi. After completing the therapeutic regime, she completely recovered and the diarrhea has not recurred for half a year.2 1 Dong Jian-hua. Successful Cases of Treating Diseases in Modern China-Dong Jian-huan’s Medical Records 中国现代名中医医案精华·董建华医案. Beijing: Beijing Publishing House; 1990. p. 1772-1773. 2 Dong Jian-hua. Successful Cases of Treating Diseases in Modern China-Qin Bo-wei’s Medical Records 中国现代名中医医案精华·秦伯未医案. Beijing: Beijing Publishing House; 1990. p. 16391640.

Comments: The patient suffered chronic diarrhea for more than ten years. The diarrhea would occur often in the day or at night. Weakness of the waist, heaviness of the limbs, and the preference for warmth on the abdomen were persistent symptoms. They reveal deficiency-cold of the kidney and a pattern of kidney diarrhea. There were concomitant symptoms of poor digestion and disorder with the transportation and transformation of the intestine and stomach, causing abdominal distension and pain relief following urgent defecation. Feverish sensations in the palms, dry mouth, and amenorrhea are symptoms of liver deficiency and constrained heat. Overall this is a complicated pattern of cold and heat in complexity, deficiency-excess complex, damp-cold accumulation, and heat constraint. When treating chronic diarrhea and long-term dysentery, Dr. Qin often used Wū Méi Wán and the expected effect was usually achieved.

Summary There are one formula within the worm-expelling formulas chapter. Wū Méi Wán is effective for syncope due to roundworms. It is indicated for paroxysmal pain of the abdomen and stomach cavity, vexatious vomiting, vomiting after eating, vomiting roundworms, cold limbs, and chronic diarrhea or dysentery.

Questions 1.Why can Wū Méi Wán be applied for chronic diarrhea and dysentery, in addition to syncope, due to roundworms? 2.Why does Wū Méi Wán combine cold and hot medicinals and combine acrid medicinals that open with bitter medicinals that descend?

CHAPTER 18

Emetic Formulas

Emetic formulas use emetic medicinals as key components. They have the therapeutic actions to dispel phlegm-drool, retained food, and poisonous substances by inducing vomit. Emetic formulas are prescribed to treat phlegm syncope, food accumulation, and mistaken ingestion of poisonous substances. The modern “emetic” method was historically referred to as “emetic therapy”. It is one of the eight treatment methods recorded in ancient literature. Emetic formulas are mainly used to induce vomiting and dispel phlegm-drool, retained food, and poisonous substances from the throat, chest, diaphragm, or epigastrium. These formulas are used to dispel pathogens, unblock accumulation and obstruction, and activate the movement of qi. They are commonly used to treat emergent illnesses such as wind-strike, mania, and throat bì due to phlegmdrool block, food accumulation in the stomach, and toxic substances retained in the stomach. These conditions require emetic therapy. Common medicinals used to induce vomiting are guā dì, lí lú, and salt. Guā Dì Săn is the most common formula in this category. Drastic and toxic, emetic formulas tend to damage stomach qi. Therefore, they should be stopped as soon as the curative effect has been achieved. Moreover, they should be used cautiously for the old, the weak, and the pregnant. Patients with profuse sputum, food retained in a very low area of the digestive tract, hemoptysis, and hematemesis are forbidden to use

emetic formulas. If vomiting is unstoppable after ingesting an emetic formula, ginger juice, cool porridge, or water can be used to stop it. Different measures should be adopted to rescue the patient if the vomiting still doesn’t stop with the aforementioned methods. If there is unstoppable qi counterflow, formulas that harmonize the stomach and descend counterflow are applied to stop it. If vomiting is not induced after using the emetic formulas, measures such as stimulating the throat with the fingers or with feathers and drinking a lot of boiled water should be taken to facilitate vomiting. After vomiting, the patient should rest in a place where there is no wind exposure in order to prevent an externally-contracted disease due to the temporary weakness. The spleen and stomach should be harmonized and protected by taking porridge. Patients should not eat oily, greasy, or food that is hard to digest following emetic therapy to prevent stomach qi from being damaged any further.

Guā Dì Săn 瓜蒂散Melon Stalk Powder Source Text Treatise on Cold Damage (Shāng Hán Lùn, 伤寒论)

Formula Ingredients

Preparation and Administration The source text states to grind equal amounts of the two medicinals into a fine powder and then sift them together. Take 2 g of the mixture with a

warm, strained decoction made from 9 g of xiāng dòu chĭ.

Formula Indications Guā Dì Săn is indicated for patterns of phlegm-drool or food stagnation in the chest and stomach cavity. The symptoms are chest or epigastric distention and hardness, feeling of vexation, feeling the need to vomit but cannot, a feeling of qi rising to the throat that causes difficult breathing, and a pulse that is slightly floating at the cùn position.

Analysis of Fundamental Pattern Pathogenesis This formula is used for phlegm-drool retained in the chest or food retention in the upper part of the stomach cavity. Patients with this syndrome usually have qi stagnation because of the phlegmdrool or food retention in the chest and upper stomach. Therefore they suffer with symptoms such as fullness and hard mass in the chest, feeling of vexation, the desire to vomit but cannot, and breathlessness due to qi rushing up to the throat. The slightly floating cùn pulse indicates that the pathogenic qi is located in the upper body. Tangible phlegm-drool and food retention in the chest are located in the upper region of the body and thereby have the tendency to exit from the upper body. We should work with this tendency in order to promote vomiting of the sputum and food retention.

Formula Actions Induces vomiting of phlegm or stagnant food.

Formula Analysis

Unique Combination Features Therapeutic vomiting is achieved through the combination of sour and bitter flavors. The stomach qi is protected while vomiting is promoted, so that vomiting will not damage the stomach.

Formula Applications 1. Essential pattern differentiation This formula is the chief prescription used to induce vomiting. This clinical pattern is marked by:

2. Modifications

3. Modern applications

This formula may be used in the following biomedically defined disorders when the patient shows signs of congested phlegm-drool: dilatation of the stomach due to food retention in the gastric cavity, toxic substances retained in the stomach, bronchial asthma, and schizophrenia. 4. Cautions and contraindications Guā dì is a bitter, cold medicinal that is toxic, so it tends to damage stomach qi. It should be used cautiously for patients with conditions other than those with excessive form and qi. Guā dì is forbidden to use once retained food has entered the intestines or if the phlegm-drool has left the chest.

Associated Formulas Sān Shèng Săn (Three Sages Powder, 三圣散) [Source] Confucians’ Duties to Their Parents (Rú Mén Shì Qīn, 儒门事亲) [Ingredients]

[Preparation and Administration] Grind the medicinals into powder and prepare it as decoction. The decoction should be taken slowly. Once vomiting appears, the decoction should be discontinued. [Actions] Vomits wind-phlegm. [Applicable Patterns]

Wind-strike block. Symptoms include: aphonia, vexation, facial palsy, unconsciousness, lockjaw, frequent epilepsy caused by congested turbid phlegm in the chest and ascending counterflow, retained toxic substances in the upper stomach, and a floating, slippery and excessive pulse,. Jiù Jí Xī Xián Săn (Emergency Drool-Thinning Powder, 救急稀涎散) [Source] Comprehensive Recording of Divine Assistance (Shèng Jì Zŏng Lù, 圣 济总录) [Ingredients]

[Preparation and Administration] Grind the medicinals into fine powder. Take 0.5 qian (1.5 g) with warm water. Once vomiting appears, the decoction should be discontinued. [Actions] Opens the orifices to induce vomiting. [Applicable Patterns] Wind-strike block. Symptoms include: profuse phlegm-drool, gurgling of sputum in the throat, breathlessness, oppressed mind, weak limbs, fainting, mildly deviated mouth, and strong, excessive, and powerful pulses. This formula can also be used for throat bì. Sān Shèng Săn, Jiù Jí Xī Xián Săn, and Guā Dì Săn are all emetic formulas. Sān Shèng Săn and Guā Dì Săn both contain guā dì. Sān Shèng Săn also contains lí lú and fáng fēng. Thereby, it is stronger to induce

vomiting; and is particularly effective for vomiting wind-phlegm. It is used for stroke and epilepsy due to the congestion of wind-phlegm. Guā Dì Săn contains chì xiăo dòu, and is weaker to induce vomiting than the other formulas. However, it has a particular action for vomiting phlegm and food retention. Therefore, it is used for phlegm-drool and food retention congesting in the chest and gastric cavity causing fullness and hard mass in the chest and breathlessness due to qi rushing to the throat. Jiù Jí Xī Xián Săn contains zào jiăo and bái fán. It is effective to open orifices and vomit phlegm-drool, so it is used for stroke patients with congestion of phlegmdrool with symptoms of gurgling sputum in the throat, breathlessness, and an oppressed mind.

Case Studies Fú liáng (伏梁) Once a woman had a knot located below her heart and above her umbilicus. It was the size of a dou (a measure for grain) and as hard as stone. All the doctors she saw diagnosed it as an ill fetus and gave her either acupuncture or abortion-inducing medicinals to remove it. Although many types of therapeutic methods were tried, the knot was still there. Then one day Dr. Zhang Zi-he saw her and said, “the knot is cold-phlegm; both of her cùn pulses are deep when pressed, is it not a sign of cold-phlegm?”He prescribed Guā Dì Săn; and as soon as she took it, she threw up 6-7 sheng of phlegm. By the time she stopped vomiting, the size of the knot decreased by half. Several days later, the same therapy was used again and this time the 23 sheng of phlegm she threw up was sticky yellow like an egg yolk and extremely stinky. Altogether the emetic method was used three times before she took Rén Shēn Tiáo Zhōng Tāng (Ginseng Middle-Regulating Decoction, ⼈参调中汤) and Wŭ Líng Săn (Five Substances Powder with

Poria, 五苓散) to promote recovery. Soon thereafter her abdomen was as flat as normal again. 1 Comments: The area below the heart and above the umbilicus is where the stomach cavity is located. The hard knot and deep cùn pulses were caused by the prolonged accumulation of coldphlegm. The phlegmdispersing method was too gentle to remove the knot and the purgative method was unsuitable because the disease was located too high in the body to be purged. That is why the emetic method was adopted to discharge the pathogen from above. Guā Dì Săn was used three times to induce vomiting so that the knot was fully removed. To prevent it from relapsing, qi-boosting, spleen-fortifying, and dampness-eliminating formulas such as Rén Shēn Tiáo Zhōng Tāng and Wŭ Líng Săn were used to treat the root of phlegm-drool.

Summary In this chapter, there is one formal formula and two associated ones. Sān Shèng Săn is the strongest emetic formula. It has a special ability to induce vomiting of wind-phlegm, so it is used to treat stroke and epilepsy caused by wind-phlegm block. Guā Dì Săn is effective for inducing vomiting of phlegm and food accumulation, so it is used to treat the phlegmdrool blocking chest and stomach. Jiù Jí Xī Xián Săn is effective for opening the closed orifices and promoting vomiting of phlegm-drool, so it is used to treat wind-strike block in patients with excess phlegm-drool.

Questions What are the indications of emetic formulas? What are the cautions when using them? 1 Zhang Zi-he. Confucians’ Duties to Their Parents 儒门事亲. Shanghai: Shanghai Science and Technology Publishers; 1959.

Appendix: List of Medicinals

Index by Chinese Formulas-Pin Yin Names A

B

C

D

E

F

G

H

J

K

L

M

N

P

Q

R

S

T

W

X

Y

Z

Index by Symptoms and Diseases A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Index by Classical Texts A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

R

S

T

U

V

W

Y

Z