internal medicine formulas - commentary

Ba Zheng San (Eight-Herb Powder for Rectificiation, p. 713) CA, NCCAOM

The Chinese prescription literature contains numerous formulas for the treatment of urinary dribbling disorders. This formula is one of the most famous, indicated specifically for the treatment of hot, bloody, and painful urinary dribbling. At present, many formulas for urinary tract infection are based on this formula. However, since urinary tract infection (usually a type of painful urinary dribbling) is not always caused by damp-heat or other forms of excess, indiscriminate use will prove to be ineffectual or even harmful. The body generally attempts to drain excess heat caused by inappropriate diet, alcohol, or drugs via the skin, bowels, urine, or even blood. This type of excess heat, which always comes from the outside, is different from the heat from constraint that is caused by the stagnation of the body's own yang qi. Excess heat readily turns into toxic heat; it readily combines with the body substances like stool, urine, and blood with which it shares routes of transport and elimination to produce clumping; and it must therefore be drained with bitter and cold herbs, rather than cleared with acrid and sweet ones. From an organ perspective, Heart patterns indicate conditions where such excess heat has penetrated into the blood aspect, causing bleeding and agitation of the spirit. Attempts by the body to drain this heat via the urine lead to damp-heat clumping and stagnating within the lower burner. Hence, the source text prescribes this formula not only for painful and bloody urinary dribbling and urinary retention, but also for heat in the Heart channel characterized by a parched throat, severe thirst, irritability, eye redness and pain, scorched lips, nosebleed, and sores in the mouth, tongue, or throat. The formula should be most effective when used in the treatment of patterns that match this presentation. The inclusion in this formula of Rhei Radix et Rhizoma (da huang), an herb more commonly associated with bowel obstruction and yang brightness-warp disorders, underscores the original intention of this formula to drain heat from the lower burner and blood aspect. Rhei Radix et Rhizoma (da huang) contributes four different actions to the overall effect of the formula. First, it drains damp-heat not only via the stool, but also via the urine. Materia Medica of Ri Hua-Zi, for instance, notes that it "promotes [both] urination and bowel [movement]." Similarly, Secret Essentials of Main Indications, a no longer extant text quoted in Expounding on the Origins of Medicine, emphasizes that it "eliminates lower burner dampness:' Second, Rhei Radix et Rhizoma (da huang) drains excess heat and resolves toxins by guiding them downward. This is useful for counteracting the innate tendency of fire to flare upward, as well as draining it from its source. Third, Rhei Radix et Rhizoma (da huang) cools the blood and stops bleeding. It enters the blood aspect and enlivens blood where it has become static, but also effectively treats bleeding from the upper body orifices by directing fire downward. Fourth, the use of Rhei Radix et Rhizoma (da huang) embodies the treatment principle of "treating upper [burner] disorders through the lower [burner]." By draining fire downward and eliminating excess through both the urine and stool, Rhei Radix et Rhizoma (da huang) removes the source of the heat that is responsible for symptoms like parched throat, severe thirst, irritability, eye redness and pain, scorched lips, nosebleed, and sores in the mouth, tongue, or throat. All of these actions are directed at eliminating excess heat. The 19th-century physician Fei Bo-Xiong thus suggests providing a substitute for Rhei Radix et Rhizoma (da huang) in cases of mixed excess and deficiency disorders: In [those with] a constitution combining yin deficiency with dampness [and] fire, one should remove Rhei Radix et Rhizoma (da huang) and add substances like Asparagi Radix (tian men dong), Sal viae miltiorrhizae Radix (dan shen), Moutan Cortex (mu dan pi), and Succinum (hu po). One must furthermore not use Rhei Radix et Rhizoma (da huang) where it would damage the primal qi of a patient.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

The contemporary physician Nie Hui-Min concisely describes the connections at the base of this formula's broad utility: Facilitating the functions of the Bladder facilitates the Triple Burner; facilitating the Triple Burner facilitates the Lung qi. One can see that Five-Ingredient Powder with Poria (wu ling san) is able to facilitate urination and unblock the water pathways and therefore it can be used for anyone with urinary dysfunction due to internal [stoppage of] water qi. Even when there are no signs of an exterior pattern, it can still be used.

Zhu Ye Shi Gao Tang (Lophatherus and Gypsum Decoction, p. 155) NCCAOM

Regarded as a variation of White Tiger Decoction (bai hu tang), this is an excellent example of how a relatively slight modification can change the entire focus of a formula. Golden Mirror of the Medical Tradition states that this "changes an extremely cold formula into a clearing and tonifying one." In Continuing Discussing Cold Damage, Zhang Lu argues that the substitution of Anemarrhenae Rhizoma (zhi mu) with Lophatheri Herba (dan zhu ye), Ophiopogonis Radix (mai men dong), and Pinelliae Rhizoma (ban xia) changes the indication of the original formula from one that treats a lurking warm pathogen to one that treats lurking heat. By removing Lophatheri Herba (dan zhu ye) and Gypsum fibrosum (shi gao) from the formula and increasing the dosage of Ophiopogonis Radix (mai men dong), one obtains Ophiopogonis Decoction (mai men dong tang), discussed in Chapter 15. This is a formula for treating dryness in the Lungs and Stomach without lingering heat. In spite of their different indications, all three formulas share a common emphasis on venting and clearing lingering heat from the qi level with acrid and cold herbs, even though in each case the yin is already damaged. Zhang Xi-Chun is the physician who best explained the reasoning behind this strategy. Relying too early on cold and sweet herbs like Radix Rehmanniae Glutinosae (sheng di huang), Scrophulariae Radix (xuan shen), Asparagi Radix (tian men dong), or Ophiopogonis Radix (mai men dong), which are aimed at replenishing fluids, obstructs the qi dynamic. This traps pathogenic heat and encourages rather than prevents the development of consumptive disorders. Originally, the formula was prescribed only for the sequelae of cold damage disorders, but its scope was expanded significantly by later generations of physicians. Straight Direction from Ren-Zhai, for instance, prescribes it for "fever from lurking summerheat blazing in both the exterior and interior [characterized] by irritability and great thirst." Prescriptions of Universal Benefit recommends it for "being struck by summerheat with thirst, irritability, vomiting, rebellious qi, and a rapid pulse." Summerheat is thus another major indication. This type of pathogen readily injures the qi and fluids and may lead to a condition characterized by high fever, profuse sweating, extreme fatigue, severe thirst, a red and dry tongue, and a rapid pulse that is also deficient or thin. Use of the formula is not limited, however, to feverish disorders and their sequelae. It can be used whenever there is evidence of excess heat in the Stomach that is accompanied by injury to the qi and yin. Fine Formulas of Wonderful Efficacy states that it treats "children who are deficient, severely emaciated, and have sparse qi, where the qi rebels causing a desire to vomit, and the four extremities are restless and the body hot." Ye Tian-Shi, in Master Ye's Patterns and Treatments in Women's Diseases, indicates its use for "irritability and thirst in pregnancy due to excess fire in the stomach channel." Dermatology experts prescribe the formula to treat prickly heat, and modern physicians use it for postoperative fever, nausea and vomiting, or for yang brightness-channel disorders such as mouth ulcers, toothache, and chronic gastritis.

Zhu Ling Tang (Polyporus Decoction, p. 731) CA, NCCAOM

What is special about this formula is its ability to promote urination without injuring the yin, and to stabilize the yin without causing the retention of pathogenic influences. In large part, this is due to the use of Asini Corii Colla (e jiao), which is better able to maintain this delicate balance than such substances as Rehmanniae Radix preparata (shu di huang). Unlike those other herbs, Asini Corii Colla (e jiao) not only tonifies the yin and nourishes the blood, it also stops bleeding and moistens the Lungs. The latter is due to its gelatinous nature and also the fact that it is prepared from a hide, which corresponds to the Lungs' governance of the skin. According to some physicians, this gives Asini Corii Colla (e jiao) a slippery quality like that of Talcum (hua shi) and thus the ability to promote urination without damaging the yin.

Zhu Sha An Shen Wan

(Cinnabar Pill to Calm the Spirit) The author of this formula, Li Dong-Yuan, is one of the masters of the Jin-Yuan period. Variations of this formula appear in different books attributed to him. In the source text, Clarifying Doubts about Injury from Internal and External Causes, this formula is simply known as Calm the Spirit Pill (an shen wan). The hierarchy of ingredients was slightly different than that presented above. There, Coptidis Rhizoma (huang lian) is designated as the chief ingredient because of its actions in relieving irritability and eliminating the damp-heat that was thought to precipitate the condition. The deputy ingredients, Glycyrrhizae Radix (gan cao) and Rehmanniae Radix (sheng di huang), are said to drain fire and tonify the qi as a means of enriching the yin and generating blood. In the latter function, they are assisted by Angelicae sinensis Radix (dang gui). The ability of Cinnabaris (zhu sha to clear fire and calm the spirit is related to its function of anchoring or 'weighing down' the floating fire. Some later commentators follow this reading and designate Coptidis Rhizoma (huang lian), or Coptidis Rhizoma (huang lian) and Cinnabaris (zhu sha), as the chief ingredients. Following this interpretation, it is possible to substitute other medicinals for Cinnabaris (zhu sha), which can no longer be used today because of its toxicity. Appropriate candidates would include Magnetitum (ci shi), Margaritiferae Concha usta (zhen zhu mu), Margarita (zhen zhu), Fossilia Ossis Mastodi (long gu), Fossilia Dentis Mastodi (long chi), Ostreae Concha (mu li), or Fluoritum (zi shi ying). According to the source text, the symptoms treated by this formula are due to "fire lurking in the blood above the diaphragm that rises and flourishes, [making it] impossible to be calm:' The formula "holds down the floating movement of yin fire in order to nourish the source qi of the upper burner." This is another example where the term 'yin fire' denotes all kinds of internal fire to Li Dong-Yuan, not just that from qi deficiency (see also the discussion of Tonify the Middle to Augment the Qi Decoction (bu zhang yi qi tang) in Chapter 8). However, all such pathological fire consumes the qi and must therefore be eliminated. In the present case, this is achieved by directing it downward and guiding its excess out of the body via the bowels and urine. Where yin fire arises from qi constraint, the opposite strategy is employed: constraint is opened up and the physiological fire is directed from below to above. In each case, the focus is therefore not only on treating a symptom pattern, but ultimately on reestablishing the normal ascending and downward-directing functions of the qi dynamic. In clinical practice, this formula is thought to be particularly effective in treating the palpitations and anxiety that occur during dreams. The thin pulse indicates that this is not just a condition of excess, but is caused, in fact, by 'yin fire: Such fire does not enter the body from the outside but is caused by internal factors. In the 16th-century Investigations of Medical Formulas, Wu Kun singles out worry, sadness, and excessive thinking as being particularly important. These prevent the qi from being directed downward and thereby damage the middle burner's function of producing blood. This implies that once the symptoms have been successfully treated, these underlying issues must be addressed to effect a more long-term solution to the problem.

Ren Shen Ge Jie San

(Ginseng and Gecko Powder) The harmonization of the Lungs and Kidneys that is the basis of this formula leads to the regulation of qi as well as water metabolism. Because the movement and transformation of qi and water within the body is so closely intertwined, whenever one is impaired, the other will also show symptoms and must be treated. Hence, as the contemporary physician Chen Chao Zu reminds us, "In all Lung conditions, no matter whether acute or chronic, the [simultaneous] regulation of fluids and qi is the catch [around which treatment turns]:' The heat in this presentation is due to stasis, thus neither strongly warming herbs to boost the Kidney yang nor yin enriching herbs to subdue the heat of deficiency are needed. Rather, this is a type of excess heat that results from the knotting of phlegm- fluids and yang qi within the upper burner. This heat must be cleared in order to open the qi dynamic, but where it has taken on form it must also be drained. This is achieved by the combination of Fritillariae cirrhosae Bulbus (chuan bei mu), Mori Cortex (sang bai pi), Anemarrhenae Rhizoma (zhi mu), and Armeniacae Semen (xing ren).

Bao Yuan Tang

(Preserve the Source Decoction) Compared to the principal formula (Si Jun Zi Tang), this variation focuses purely on tonification without moving stagnation or draining dampness.

Di Tan Tang

(Scour Phlegm Decoction) This is a Ming-dynasty formula that combines several older formulas to achieve a new effect: Two-Aged [Herb] Decoction (er chen tang), discussed above, the basic formula for drying dampness and transforming phlegm; Four-Gentlemen Decoction (si jun zi tang), discussed in Chapter 8, a core formula for tonifying the qi; and Settle the Emotions Pill (ding zhi wan), discussed in Chapter 10, which treats phlegm obstructing the qi transformation of the Heart. To these has been added a large dosage of Arisaematis Rhizoma preparatum (zhi tian nan Xing) because Of its ability tO eliminate wind-phlegm from the channels and collaterals and its specific indication for wind-stroke. Although there is a tonifying aspect to this formula, the pattern treated is one of acute excess. Accordingly, once the acute symptoms have been resolved, a more moderate and less drying formula should be employed. Any deficiency present is a deficiency of the nutritive qi associated with dampness or dryness disorders as well in the channels and collaterals. Viewed from this perspective, one can interpret the use of Ginseng Radix (ren shen), Glycyrrhizae Radix (gan cao), and Poria (ju ling), all of which enter not only the Spleen but also the Heart, as a means of ensuring an adequate supply of clear nutritive qi to compensate for what has been transformed into pathological phlegm- ampness. Many commentators, nevertheless, consider the use of Arisaematis Rhizoma preparatum (zhi tian nan xing) as being too drying and recommend that it be replaced with Arisaema cum Bile (dan nan xing), which is bitter, cooling, and moistening in nature. Several later formulas by the same name go even further and add herbs such as Coptidis Rhizoma (huang lian) or Scutellariae Radix (huang qin). This implies that the patient's constitution is very strong, and that long-term phlegm stagnation has caused the yang qi to become constrained so that it eventually combines with the phlegm and forms phlegmfire. The inclusion of Bambusae Caulis in taeniam (zhu ru) in the original formula can also be interpreted from this perspective. In contemporary practice, this formula is most commonly used in treating impaired speech following wind-stroke due to phlegm veiling the orifices of the Heart, and thus the tongue. Its efficacy in treating such patterns may be improved by adding other herbs, such as Scorpio (quan xie), that resolve spasms. It can also be used to treat epilepsy with a similar presentation. Based on the actions of its constituent ingredients, its use has been expanded to include wheezing with copious sputum and focal distention and fullness in the chest due to obstruction of the qi in the chest by phlegm, as well as to other problems commonly attributed to phlegm pathologies such as severe dizziness, insomnia, or loss of motor function in disorders such as multiple sclerosis or motor aphasia.

Dang gui shao yao san

(tangkuei and peony powder) Abdominal pain has many causes. The classical usage of this formula is for the treatment of sustained pain (xiu tong). This pain is milder but more continuous than that for which Ass-Hide Gelatin and Mugwort Decoction (jiao ai tang) is indicated, and there is no bleeding. Its pathodynamic is described by the Ming-dynasty physician Xu Bin in Discussion and Annotation of the Essentials from the Golden Cabinet: Sustained pain denotes continuous pain. It is not like the gripping pain of cold-type bulging disorder, nor the stabbing pain of qi or blood [stagnation]. Insufficiency of the normal qi allows yin to encroach on yang so that water qi prevails over earth. Spleen [qi] is constrained and unable to extend but seeks to [overcome] the constraint by extending itself. This dysregulation of the Spleen qi manifests as continuous pain. However, jiao tang, which means hypertonic or 'tense pain.' Some commentators, like the contemporary physician Yue Mei-Zhong, utilize this definition in their understanding of the formula's clinical presentation: The pattern [treated by] this formula [presents with] hypertonicity and pain of the central abdomen that may extend upward to the epigastrium or the chest. There may be urinary difficulty. Pain may prevent bending forward or backward. On abdominal diagnosis, the abdomen along the sides of the umbilicus (i.e., the rectus abdominus muscle) will be tender and hypertonic. Alternatively, pressing on the left will shift [fluid] to the right and vice versa. [This feels] as if there were something in the abdomen, but there are no lumps. This [pattern] belongs to blood and water stopping and stagnating. Yet another translation of the characters 15 7% is 'slight pain.' There is no agreement among commentators regarding the correct interpretation of the term in the present context. Rather than seeking for the right solution, it may thus be more useful clinically to follow the analysis of the contemporary physician Huang Huang in One-Hundred Classic Formulas, who states that this formula treats all kinds of pain extending from cramping to aching, provided that it fits into the overall manifestation of the pattern for which this formula is indicated.

Dang gui shao yao san

(tangkuei and peony powder) Although the location of the pain in the central abdomen around the umbilicus defines this as being primarily a Spleen pathology, its nature (hypertonicity of the abdominal wall) also refers to Liver wood. In Chinese medicine, the physiological functions of the Liver with regard to qi are referred to as 'dredging and draining.' This implies a keeping open of the channels that relies, on the one hand, on the dispersion of qi and blood from the lower to the upper burner, and, on the other, a draining of excess yin water from the body. This formula achieves both of these functions by combining herbs that tonify the qi, invigorate the blood, and drain fluids. This is outlined, once more, by Yue Mei-Zhong, who states that the ingredients of this formula: Used together, dredge the blood that has stagnated and become static, but also disperse constrained built-up water. If after taking it the urine becomes [ dark]like blood, or the stools become watery, this means that the medicine has fastened onto the disorder, which is excellent. To treat hardness, it needs to be taken long-term. Understanding the functions of the formula in this way has widely extended its scope of application. The Song-dynasty text Discussion of Illnesses, Patterns, and Formulas Related to the Unification of the Three Etiologies observes: "Taken regularly, it facilitates unimpeded [movement through the] blood vessels to prevent abscesses and sores, eliminates phlegm, nourishes the Stomach, brightens the eyes, and benefits the yang fluids.'' For many gynecologists, this formula has thus become the preferred choice for treating gynecological problems due to deficiency that involve blood stasis and water buildup, including the treatment of infertility, malposition of the fetus, edema, pain or bleeding during pregnancy, dysmenorrhea, and irregular menstruation. Because it focuses on the blood aspects of Liver dysfunction and the damp aspects of Spleen dysfunction, many practitioners prefer to use it instead of Frigid Extremities Powder (si ni san) or Rambling Powder (xiao yao san) in cases of Liver/Spleen disorders when the pain is not accompanied by distention. Viewing pain that involves both blood stasis and water buildup as the key problem treated by this formula has resulted in the expansion of its scope of action to other problems in women, and then to the treatment of similar problems in men. Pain invariably will be the main symptom, although this can occur anywhere in the body and not just the abdomen. Water buildup may manifest in any number of ways, including excessive discharges or dryness resulting from dampness obstructing (as in allergic rhinitis); dizziness, nausea, heavyheadedness and reduced urination indicating accumulation of thin mucus (as in Meniere's disease); sensations of fullness and obstruction in the chest and epigastrium from thin mucus (as in coronary heart disease); swellings in the abdomen or increased sweating from the lower body (as in ovarian cysts or hydrocele); and constipation or urinary difficulty indicating obstruction of the qi dynamic by dampness in the lower abdomen. This combination of pain and fluid accumulation is thus a key marker for the formula's use in clinical practice. These symptoms may be accompanied by cold (either a subjective aversion to cold or coldness of the extremities), fatigue (indicating deficiency), and some kind of visible edema (often around the eyes).

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

Located in between the exterior and the interior and responsible for regulating the distribution of qi throughout the body, the lesser yang is referred to in Chapter 6 of Basic Questions as functioning like a 'pivot' (shu). When the pivot becomes stuck, the qi dynamic breaks down. This gives this formula an extremely wide range of possible indications. The formula is mentioned over twenty times in Discussion of Cold Damage and Essentials from the Golden Cabinet. Paragraph 101 of Discussion of Cold Damage observes that "For cold damage or wind attack, when there is a presentation associated with this formula, if there is only one sign, then that is it. It is not necessary that they all be present [to make the diagnosis]." This statement sparked considerable discussion among commentators. Some interpreted it literally to mean that the presence of just one of the signs or symptoms listed in the source text warranted the use of Minor Bupleurum Decoction (xiao chai hu tang). Others, however, read it as referring to the presence of just the chief signs (zhu zheng) like alternating chills and fever, fullness of the chest and hypochondria, downcast demeanor with lack of appetite, or irritability and nausea. The late-Qing-dynasty physician Tang Zong-Hai prescribed this formula for a wide variety of problems. In Discussion of Blood Patterns, Tang's interpretation of its efficacy focuses on the relationship between the Gallbladder and Triple Burner within the lesser yang warp. In his discussion of pathophysiology, Tang's description provides one of the clearest expositions of this formula and its associated pattern: This is an invigorating formula that spreads out the exterior and harmonizes the interior, that lifts the clear upward and directs the turbid downward. The exterior of the human body [in this context refers to] the pivotal dynamic of the interstices and pores and the nutritive and protective [aspects]. The interior of the human body [refers to] the substantial supervisory function [exerted by] the Triple Burner on the yin and yang organs. In the interior, the lesser yang governs the Triple Burner, in the exterior it governs the interstices and pores. If we are discussing the nature of the lesser yang, we [mean] the qi of the ministerial fire with its root in the Gallbladder. If we are discussing its function, we [mean) the qi of clear yang that resides in the Stomach. The formula uses Ginseng Radix (ren shen), Jujubae Fructus (da zao), and Glycyrrhizae Radix (gan cao) to develop the patient's Stomach [qi]. It uses [the combination of] Scutellariae Radix (huang qin) and Pinelliae Rhizoma preparatum (zhi ban xia) to direct turbid fire downward, and [the combination of] Bupleuri Radix (chai hu) and Zingiberis Rhizoma recens (sheng jiang) to lift up the clear yang. Thus harmonizing and facilitating the patient's qi [dynamic], how would the interstices and Triple Burner not also be regulated? Where the qi of the greater yang sinks into the anterior aspect of the chest from where it has no way out, one can also use this formula to clear the interior and harmonize the middle, raising and spreading the qi so that it does not clump but releases any exterior condition. Where fire constrains the Lung channel, inhibiting urination and the bowels, one uses it to disperse and unblock the upper burner. When the body fluids no longer clump, [urine and bowels] spontaneously [properly] move in the lower burner. One also uses it for fire from constraint in the Liver channel in order to guide Liver qi to spread upward so that wood is no longer constrained. Because [the formula] also contains substances that clear and direct downward, any remaining fire will definitely also be eliminated.

Huang Lian Wen Dan Tang (Coptis Decoction to Warm the Gallbladder

for severe phlegm-heat with more restlessness and irritability, and a more intense bitter taste in the mouth than in the principal formula

Dang gui shao yao san

(tangkuei and peony powder) The action of the formula can further be modified by adjusting the relative dosage of its ingredients. This includes making a judgment with regard to the type of Paeoniae Radix (shao yao) to be used, as the source text did not yet distinguish between Paeoniae Radix alba (bai shao) and Paeoniae Radix rubra (chi shao). Depending on what type of Paeoniae Radix (shao yao) one uses, or in which combination one combines the two types, one can accentuate one or more of the following effects: • Relaxing hypertonicity and alleviating the pain • Nourishing the blood and softening the Liver • Invigorating the blood and unblocking the vessels • Promoting fluid metabolism. Paeoniae Radix alba (bai shao) is considered superior at achieving the first and second of these goals, as its sour and sweet tastes focus on preserving the yin as a means of controlling the yang. The cold, unblocking, and draining nature of Paeoniae Radix rubra (chi shao) is more appropriate where the latter goals are considered to be of primary importance. Furthermore, because of its blood-invigorating properties, Paeoniae Radix rubra (chi shao) should only be used with care if this formula is prescribed during pregnancy.

Xian Fang Huo Ming Yin (Sublime Formula for Sustaining Life, p. 861)

A commonly used alternative name for this formula is True Person's Formula for Sustaining Life (zhen ren huo ming yin). In Daoism, 'true person' is another name for an immortal.

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

A passage in Rectification of the Meaning of Materia Medica explains the action of the chief herb in this formula, Bupleuri Radix (chai hu), and its role in the process of harmonizing resolution: Bupleuri Radix (chai hu) has a bitter flavor and therefore specifically focuses on pathogenic heat ... It grows in the early spring, its qi is fragrant, and its character light and clear. With both a light qi and flavor and an ascending, discharging nature constitutionally received in the spring, it is thus completely different, however, in both character and function from other bitter, cooling, draining, and downward-directing herbs .... When pathogenic qi gradually enters into the interior and is no longer located merely at the muscle layer and surface [of the body] from which all other exterior-dispersing herbs can no longer vent it, only Bupleuri Radix (chai hu) with its clear and light qi and aromatic fragrance is able to dredge and drain it, guiding and lifting the pathogenic qi outward to be resolved via the exterior. This is why Bupleuri Radix (chai hu) is [included among the herbs that] resolve the exterior, even if its action is different from other herbs that focus on resolving the exterior.

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

A third important point of historical debate concerns the function and dosage of the chief herb Bupleuri Radix (chai hu). From the Jin-Yuan period onward, physicians linked the ability of Bupleuri Radix (chai hu) to dredge Liver and Gallbladder qi and resolve the exterior to its capacity to lift up the yang qi. This is an elegant way of tying all of the many possible applications of this herb to one explanatory model. However, lifting up the yang qi is another way of saying that Bupleuri Radix (chai hu) stimulates the body's transformation of essence (water) into qi (fire). Some physicians thus became worried about the potential side effects of using Bupleuri Radix (chai hu). They argued that Bupleuri Radix (chai hu) and other uplifting herbs like Puerariae Radix (ge gen) "plunder the yin" (jie yin) and should thus be used only with extreme circumspection. Owing to diverse cultural and social factors, these ideas became very influential among physicians and patients in southern China from the 16th century onward. These perceptions are an important reason for the large discrepancy between the dosage of Bupleuri Radix (chai hu) prescribed in the source text and the much lower dosage used by most modern practitioners. The latter believe that while the herb is quite safe for most patients, it should be used with caution in those with yin deficiency. Other physicians, however, reject the entire explanatory framework on which these concerns are based. They point out that before Jin and Yuan dynasty physicians began describing this herb as lifting up the yang, it had been primarily used to open up obstructions. According to the Divine Husbandman's Classic of the Materia Medica, "Bupleuri Radix (chai hu) ... governs clumping of qi in the Heart [i.e., the epigastrium], abdomen, bowels and Stomach, accumulation of food and drink, [as well as] fever and chills[ caused by] pathogenic qi. lt pushes out the old for the new to arrive:' In pre-Song manuals like Important Formulas Worth a Thousand Gold Pieces or Arcane Essentials from the Imperial Library, Bupleuri Radix (chai hu) was thus used in accordance with quite different parameters than in later texts, namely, to dispel stasis in cases of mobile abdominal masses or menstrual irregularity, including amenorrhea; to resolve fever, including the fever of malaria and of consumptive disorders; and to drain downward by opening the digestive pathways. When cultural shifts during the Qing dynasty stimulated a critical reexamination of Song-Jin-Yuan medicine, such older views gained new currency. Writers such as the 20th century physician Zhang Ci-Gong, whose Discussing Medicinal Substances influenced generations of students in modern China, now completely rejected the proposition that Bupleuri Radix (chai hu) lifted up the qi. He argued that it must be used in a large dosage and is only appropriate for opening obstructions. His disciple, Zhu Liang-Chun, one of contemporary China's most influential clinicians who is renowned for his understanding of materia medica, tried to forge a compromise. In Collected Experiences of Zhu Liang-Chun in Using Medicines, Zhu argued that, depending on the dosage, Bupleuri Radix (chai hu) either lifts up the qi or unblocks by draining downward. For the former, useful in cases of qi constraint due to internal Liver disharmonies, Zhu recommends a dosage of 3-10g. For the latter, appropriate where constraint is caused by external pathogens, he recommends a dosage of 20-30g. Zhu also argued that the key sign for the use of Bupleuri Radix (chai hu) is a white and often relatively dirty and greasy tongue coating. This reflects the accumulation of phlegm fluids that is the invariable consequence of qi and fluid constraint, for which Bupleuri Radix (chai hu) is specifically indicated.

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

According to Discussion of Cold Damage, the common methods of treating externally-contracted diseases are inducing sweating (to release the exterior) and purging or vomiting (to expel interior accumulations). However, neither of these approaches is appropriate for treating a lesser yang disorder. The pathogenic influence is lodged too deeply in the interior to be released by sweating, which would only injure the fluids and the normal qi. Yet the pathogen has not penetrated deep enough to justify purging, which would injure the yin and could lead to palpitations with anxiety. Because the symptom of chest fullness is due to qi constraint rather than pathogenic accumulation, inducing vomiting is also inappropriate. This would merely injure the yang of the chest and could lead to palpitations. The preferred method, which unblocks the qi dynamic to clear heat constraint, vents pathogens from the lesser yang, and harmonizes fluid metabolism; it is known as harmonization, or literally 'harmonizing resolution' (he jie).

Tong Xie Yao Fang (Important Formula for Painful Diarrhea, p. 125) NCCAOM

According to the famous 20th-century physician Qin Bo-Wei, the pathogenesis of this disorder is that the deficient Spleen condition with abdominal distention usually occurs first. This causes the Liver to overcontrol the Spleen, with symptoms of abdominal pain and later diarrhea. The diarrhea is marked by a few distinguishing characteristics: it is relatively meager in volume; the patient feels more comfortable after each bowel movement; and the problem is recurrent. Qin noted that the pulse is usually wiry, thin, and transposed. By 'transposed' he meant that the right (Spleen) pulse is stronger than the left (Liver) pulse, which is a common, if paradoxical, sign of the Liver overcontrolling the Spleen. Regardless of which of the two organs is more affected, this condition often recurs during times of stress and Liver constraint. There has been some discussion regarding why Saposhnikoviae Radix (fang feng) is used in this formula instead of Bupleuri Radix (chai hu), which is more commonly associated with treating Liver constraint. Four reasons are cited: 1. Saposhnikoviae Radix (fang feng) enters the Liver where its acrid flavor disperses constraint. 2. It enters the Spleen and Stomach and is frequently used as an envoy to guide other herbs into these organs. According to Li Dong-Yuan, "If one wants to tonify the Spleen and Stomach, [other herbs] will not move there unless guided by Saposhnikoviae Radix (fangfeng):' 3. Its acrid and bitter flavors overcome dampness, while its nature is to ascend. By facilitating the ascent of clear qi, Saposhnikoviae Radix (fang feng) thus stops diarrhea. 4. Saposhnikoviae Radix (fang fen g) tracks down and expels wind from the interior of the body, especially from the Intestines. This function is useful if the diarrhea is due to an external pathogen. Symptomatically, it treats borborygmus, which is also considered a type of wind. In line with the emphasis on the treatment of wind suggested by the use of Saposhnikoviae Radix (fang feng), in the contemporary book Collected Medical Writings of Li Ke-Shao, that physician argues that this formula is most suitable for treating spasmic diarrhea, reflected in a wiry pulse: Irrespective of whether it is an acute or chronic disorder, and even when it is a case of daybreak diarrhea [which normally indicates Kidney deficiency], the only important [diagnostic] marker is the wiry pulse, or the spasmodic abdominal pain that accompanies [the diarrhea], or other symptoms that clearly indicate that the Liver qi is too strong.

Gan lu yin

All yang brightness-warp patterns are characterized by heat excess and damage to the yang fluids. The customary treatment strategy at this stage is to focus on clearing and draining pathogenic heat. This orders the qi dynamic and prevents further damage to the fluids. In this case, however, the dry tongue and sore throat in the absence of signs indicating knotting of heat in the interior suggests that dryness is predominant. For this reason, the formula focuses on generating fluids as the primary route for supporting the normal qi. The use of this formula has been expanded recently to include treatment of some eye disorders (the Stomach channel terminates near the eyes) as well as other conditions with yin deficiency and damp-heat.

Liang Ge San (Cool the Diaphragm Powder, p. 176) NCCAOM

Almost all commentators agree that the formula clears and drains heat from the upper and middle burners. Their views regarding the relative importance of each herb in the formula vary depending on which of the two actions they consider to be primary. A minority even extends the formula's action to all three burners. The mid -19th century scholar-physician Fei Bo-Xiong, for instance, argued that the combination of Rhei Radix et Rhizoma (da huang) and Natrii Sulfas (mang xiao) also drains heat from the lower burner. Ding Xue-Ping, a contemporary physician from Shanghai, provides another divergent commentary in Modern Explanations of Ancient Formulas: This [formula] represents a joint strategy of dredging wind with acrid and cooling [substances], draining fire with bitter and cold [substances], and thrusting out [pathogens] via purgation with salty and bitter [substances. Its authors thereby] established the correct way [to treat] pathogenic fire that collects and clumps in the exterior, the interior, and the Triple Burner [simultaneously]. In Convenient Reader of Established Formulas, the late-Qing dynasty physician Zhang Bing-Cheng focused on describing the disease dynamic that leads to this pattern: All the various manifestations of this pattern outlined above are due to pathogenic fire in the upper and middle burners that is accompanied by clumped matter in the Stomach [made up of] harbored food or stools. Fire that has scattered, irrespective of whether it is [now] located in the interior or exterior, can be cured by clearing and dispersing. However, if [such fire] is accompanied by formed matter that has clumped and not been dispersed, one cannot completely recover from such an illness unless this clumping is [also] eliminated. This explanation helps us understand the views of the late 17th-century physician Zhang Lu who thought that this formula works best for problems caused by a seasonal warm pathogen disorder. The source text also indicates its use "for any type of wind clogging [the qi dynamic]" (qie feng yang). Wind-heat pathogens quickly penetrate into the body and can thus remain in the exterior (upper burner, Lungs), even as they are already entering into the interior (middle burner, Stomach). The Triple Burner, represented in the formula's name by the diaphragm, connects the exterior and interior, and must of necessity be involved in any such process. This is comparable to a combined disorder of all three yang aspects in a cold damage disorder, which also necessitates a complex treatment strategy that hinges on the lesser yang. The difference is that in a warm pathogen disorder, heat in the exterior must be vented by means of light, acrid, and cooling herbs, whereas in a cold damage disorder, it is dispersed by means of acrid, warming herbs. The scope of this formula's application has been extended to the treatment of childhood convulsions, macular rashes, and various types of pox where the heat evolves into such intense fire that it produces extremely dark, collapsed sores. Some practitioners use it for any type of skin disorder associated with the accumulation of heat in the upper and middle burners.

Pu Ji Xiao Du Yin (Universal Benefit Decoction to Eliminate Toxin, p. 173) NCCAOM

Although early observations of this disorder were recorded in the Yellow Emperor's Inner Classic, the understanding of its etiology and pathogenesis became more sophisticated during the Jin and Yuan dynasties, and perhaps was even better understood by the warm pathogen disease current of the Qing dynasty. Therefore, the Chinese medical literature discusses the disorder under a range of different names. Most writers, however, agree that Li Dong-Yuan's formula constitutes the treatment of choice. This consensus is reflected in a passage from Wu Ju-Tong's Systematic Differentiation of Warm Pathogen Diseases: "Treatment strategies [for this disorder] cannot go beyond Li Dong-Yuan's formula)." Nevertheless, Wu Ju-Tong felt entitled to make major adjustments to the use of the formula in the clinic. Noting that the inherent momentum of the disorder involved the excessive accumulation of heat toxin in the upper body and head, he suggested removing Bupleuri Radix (chai hu) and Cimicifugae Rhizoma (sheng ma) and replacing them with Lonicerae Flos (jin yin hua) and Schizonepetae Herba (jing jie). He argued that the addition of these light substances ensured that the formula would focus on the upper burner and head with little risk of guiding even more qi to this area. Such reasoning reflects a fundamental difference in style between Li Dong-Yuan's emphasis on supporting the body's normal qi and Wu Ju-Tong's adherence to the principles of the warm pathogen disease current, with its emphasis on the use of 'light substances to eliminate serious [disorders].' If the latter approach tries to prevent newly-contracted pathogens from moving deeper into the body, the Jin-Yuan medicine that Li Dong-Yuan represents concentrates, instead, on supporting the body's resistance. These concerns not only underpin his use of Cimicifugae Rhizoma (sheng ma) and Bupleuri Radix (chai hu), which are intended to facilitate the ascent of yang qi, but also explain the inclusion of a tonifying herb like Ginseng Radix (ren shen) in a formula intended to resolve toxicity and clear heat. The contemporary consensus is to include Ginseng Radix (ren shen) only if the patient's consitution or presentation demands it. No such consensus exists regarding the use of Cimicifugae Rhizoma (sheng ma) and Bupleuri Radix (chai hu). Those advocating inclusion refer to the well-established treatment strategy of discharging heat from constraint. They also point out the synergistic effects that arise from the combination with Coptidis Rhizoma (huang lian) and Scutellariae Radix (huang qin). Because these herbs drain fire downward, their matching balances out any excessive ascending or downward-directing effect that each pairing might cause on its own. Proponents of the warm pathogen disease therapeutics, such as the Qing-dynasty physician Ye Lin, replied that such rationalizations cannot make up for Li Dong-Yuan's basic mistake. His own compromise was to omit Coptidis Rhizoma (huang lian) and Cimicifugae Rhizoma (sheng ma), but retain Scutellariae Radix (huang qin) and Bupleuri Radix (chai hu). This argument, in turn, is based on Ye's own understanding of warm pathogen disorders as arising from lurking pathogens (fu xie). According to the doctrines laid out in Supplemental Critical Annotations to the Systematic Discussion of Warm Pathogen Diseases, these lurking pathogens usually vent through the lesser yang and therefore justify the use of Bupleuri Radix (chai hu) and Scutellariae Radix (huang qin).

Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction, p. 738) NCCAOM

Although from an organ-based perspective, deficient type thin mucus is associated with Spleen and Kidney yang deficiency, the treatment is directed at harmonizing the fluids and qi dynamic rather than focusing on specific organ functions. As noted above, this was underscored by Zhang Zhong Jing in Essentials of the Golden Cabinet when he noted that thin mucus should be treated by harmonization with warming herbs. Harmonization here implies the regulation of yin and yang, water and fire. The intention is to employ warming herbs like Cinnamomi Ramulus (gui zhi) to stimulate the body's own fluid metabolism and thereby create a more physiological balance between yin and yang. Resolving thin mucus through the urine is extremely important in this pattern for another reason: seeking to disperse fluids by promoting sweating will, according to the source text, lead to "pulsation of the vessels and shaking of the body:' The reason is that, when excess fluids are located in the interior, mobilizing the yang toward the exterior will lead to a dangerous imbalance between yang on the outside and yin on the inside. Thus, it is by harmonizing water and fire that the formula is able to treat a wide range of vasomotor dysfunctions like dizziness, palpitations, hot flushes, and tinnitus, for which it is specifically indicated. In Discussion of Blood Patterns, the 19th-century physician Tang Zong-Hai elaborates: Cinnamomi Ramulus (gui zhi) tonifies the Heart fire so that is descends to connect with the Kidneys. Poria (fu ling) promotes Kidney water so that it does not insult the Heart above. In fact, Poria (fu ling) is a Spleen herb. Earth can control water so that water does not insult fire. Cinnamomi Ramulus (gui zhi) is a Liver herb that transforms water. The Liver is the child of the Kidneys. In case of excess, one drains the child. The Liver also governs dredging and draining and therefore possesses the function of transforming water qi. [With regard to] tonifying the Heart fire, in [cases of] deficiency, one tonifies the mother. Liver is the mother of Heart fire. Furthermore, Cinnamomi Ramulus (gui zhi) is red and enters the Heart. To promote sweating, one uses Cinnamomi Ramulus (gui zhi), drawing on the warmth of wood qi to disperse and thrust outward. To direct upward-gushing and rebellion downward, one also uses Cinnamomi Ramulus (gui zhi) because the Penetrating vessel connects with the Liver below and with the Kidneys internally. Cinnamomi Ramulus (gui zhi) warms the Liver qi to draw it out and warms Kidney water in order to drain it. Whenever cold water attacks the lower burner [leading] the yang of the Penetrating [vessel] to float upward, one can often assist it with Poria (fu ling) and Pinelliae Rhizoma preparatum (zil ban xia) to achieve success.

Liu Jun Zi Tang (Six Gentlemen Decoction, p. 311)

Although it is a variation of Four-Gentlemen Decoction (si jun zi tang), this formula has become a major formula in its own right, spawning a multitude of new formulas that take it, rather than FourGentlemen Decoction (si jun zi tang), as their model.

Yin Qiao San (Honeysuckle and Forsythia Decoction, p. 36) CA, NCCAOM

Although physicians began to question the usefulness of the established cold damage doctrine for the treatment of febrile disorders from the late Song onward, their understanding of pathology remained tied to existing intellectual frameworks for several more centuries. For example, the physician Liu Wan-Su, widely regarded as the first ancestor of the warm pathogen disease current in Chinese medicine, thought that fire could be traced to the invasion of a cold pathogen that underwent a process of constraint and transformation. The efforts of Wan and others in treating warm pathogen diseases by clearing or draining heat from the interior thus constituted an extension of existing cold damage therapeutics, rather than a radical departure. Cool the Diaphragm Powder (liang ge san), discussed in Chapter 4, is an important and influential example of this approach. It was only from the late Ming onward that new theories gradually emerged that posited the invasion of foul turbidity (hui zhuo) and warm pathogens directly into the body. In this new context, where the goal was to arrest the disease process as early as possible before heat entered the interior, the traditional cold damage therapeutics became much more problematic. In the first place, while bitter, cold herbs were useful for draining interior heat and resolving fire toxin, they also inhibited the qi dynamic and thereby prevented the venting of pathogens to the outside. Second, bitter herbs that eliminated pathogens via the bowels and urine would also push pathogens from the exterior into the interior and thereby accelerate the natural progression of warm pathogen diseases. Finally, the acrid and warm herbs that had heretofore been used to release the exterior were inappropriate for treating direct invasion of heat. A solution to these problems was offered by physicians like Yu Chang and Ye Tian-Shi, who proposed to combine herbs into formulas that were simultaneously acrid, cool, light, and aromatic. Wu Ju-Tong's composition of Honeysuckle and this formula clearly reflects this influence, as he was at pains to point out: The [composition] of this formula painstakingly honors the teachings of the Yellow Emperor's Inner Classic [that had recently been placed at the heart of Ye Tian-Shi's approach to the treatment of early stage warm pathogen heat disorders] ... It also follows the doctrine advocated by Yu Chang of expelling foulness by means of fragrant and aromatic herbs. I have utilized Li Gao's [i.e., Li Dong-Yuan's] formula Clear the Heart and Cool the Diaphragm Powder (qing xin liang ge san), which employs acrid, cold, bitter, and sweet [ingredients]. However, [because of what I have said regarding] the early stage of a [warm pathogen heat] disorder, I have taken out Scutellariae Radix (huang qin), which enters the interior, so as not to attack the middle burner [and guide pathogens inward]. I have added the acrid and cool Lonicerae Flos (jin yin hua) and the aromatic and fragrant Schizonepetae Spica (jing jie sui) to disperse heat and resolve toxicity. [I have also added] Arctii Fructus (niu bang zi), which is acrid, balanced, and moistens the Lungs. It resolves heat and disperses clumps, eliminates wind and improves the condition of the throat. All of these [additional] herbs [have been selected because they] enter the hand greater yin.

Huo Xiang Zheng Qi San (Agastache Powder to Rectify the Qi, p. 691) CA, NCCAOM

Although the formula simultaneously disperses the exterior and regulates the interior, its cold-dispersing and exterior-releasing powers are mild compared to its ability to transform dampness. Hence, it can also be used where no pathogens are present in the exterior. As the Ming-dynasty physician Wu Kun notes in Investigations of Medical Formulas: "If there is no wind-cold in the exterior, the two substances [Perillae Folium (zi su ye) and Angelicae dahuricae Radix (bai zhi)] are still able to discharge the Spleen gi." Likewise, the inclusion of Atractylodis macrocephalae Rhizoma (bai zhu) and Poria (fu ling) in the formula does not imply that patients for whom this formula is indicated need present with marked signs of deficiency. Rather, by augmenting the Spleen's gi, they strengthen its ability to transport and transform and thereby eliminate excess dampness.

Tong Qiao Huo Xue Tang (Unblock the Orifices & Invigorate the Blood Decoction)

Although this formula is commonly interpreted to focus on the head and face, its author, Wang Qing-Ren, stated that it is able "to unblock the blood pipes" (tong xue guan). He also noted that the bluish blood vessels that become visible on the skin are a distinguishing sign for blood stasis in the blood pipes. Contemporary commentators such as the Shaanxi College of TCM therefore interpret the term 'unblocking the orifices' (tong qiao) to mean not just the sensory organs of the head, but more generally the small apertures through which the blood enters and exits as it circulates through the body.

Zhu Ling Tang (Polyporus Decoction, p. 731) CA, NCCAOM

Although this formula tonifies the yin, its main focus is on promoting urination, unblocking the waterways, and clearing heat, that is, on treating excess. The lower abdomen may thus be tense or tender to pressure, a sign that is absent in yin deficiency. Another telling sign of this pattern is a red tongue, which indicates stagnation, with a coating that may be white or absent depending on the patient's constitution. The contemporary physician and teacher Cheng Men-Xue describes this tongue: [The tongue body will be] red like paper stained with menstrual flow. It is a dark, dull, dry red. This is very different from the shiny, fresh red [tongue that indicates] heat exuberance. One must distinguish these [two types] in the clinic. Whenever one observes such a tongue accompanied by reduced urination, especially if there is also Heart irritability and insomnia, one can unhesitatingly prescribe [this formula knowing that it] will fit [the pattern].

Ge Gen Huang Qin Huang Lian Tang (Kudzu, Scutellaria and Coptis Decoction, p. 292) NCCAOM

Although this formula treats both the interior and exterior, its primary focus is on draining interior heat. Referring to this condition, Medical Formulas Collected and Analyzed notes that "The pathogenic influence being driven into the interior is seven-tenths [of the condition]; its lingering in the exterior is three-tenths." Discussion of Cold Damage (paragraph 34) observes that this condition is due to improperly treating a greater yang disorder by purging when it should have been treated with the exterior-releasing Cinnamon Twig Decoction (gui zhi tang). For this reason, the ensuing pattern can be regarded as a simultaneous greater yang and yang brightness disorder. The early modern scholar-physician Yun Tie-Qiao went even further and argued that the formula only drains interior heat. His view was that if a pathogen was still left in the exterior, one should only use Cinnamon Twig Decoction (gui zhi tang) or Kudzu Decoction (ge gen tang). Contemporary teaching manuals like Explicating the Discussion of Cold Damage have followed Yun's lead. They hold that the function of the herb Puerariae Radix (ge gen) is to clear heat and raise the yang and that once the heat has been drained from the interior, the sweating and wheezing will stop, too. Cheng Men-Xue, a famous modern physician and former head of the Shanghai College of Chinese Medicine, offered yet another innovative interpretation. He argued that the formula treats dysentery caused by a lurking pathogen, which, according to Chinese medical doctrine, collects and develops most often in the yang brightness warp. The bitter, cold herbs in the formula drain this lurking heat toxin. Chinese medical doctrine also holds that lurking pathogens trigger a disorder only when the invasion of a new pathogen arouses the body's antipathogenic qi into action. In Cheng Men-Xue's opinion, Puerariae Radix (ge gen) is included in the formula to release this new pathogen from the muscle layer and discharge heat constraint.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

Another issue among commentators has been the question of whether Cinnamomi Cortex (rou gui) should be substituted for Cinnamomi Ramulus (gui zhi). The chief proponent of this view was the influential Qing-dynasty scholar Wang Ang. Others, like Lu Yuan-Lei, the famous modernizer of the Republican era, instead insisted on the use of Cinnamomi Ramulus (gui zhi) in Zhang Zhong-Jing's original formula. Still others, like the Qing-dynasty physician Zhang Lu, believed that both could be used according to context. The 19th -century physician Fei Bo-Xiong offered an insightful compromise. He argued that if the formula is used to treat the pattern for which it was originally conceived (i.e., one where the qi dynamic in both the exterior and interior is obstructed), then Cinnamomi Ramulus (gui zhi) must be used. If, on the other hand, one uses the formula to treat interior disorders like cold-dampness, a use to which it was put by later generations of physicians, then Cinnamomi Cortex (rou gui) is more appropriate.

Gan Lu Xiao Du Dan (Sweet Dew Special Pill to Eliminate Toxin, p. 702)

Another name for this formula that is no longer used is Universal Benefit Special Pill to Resolve Toxicity (pu ji jie du dan). This name resonates with the above indication inasmuch as it can be given to anyone afflicted by such a disorder irrespective of age, constitution, or other factors that would influence the manifestations of a normal seasonal disorder. The influential Qing-dynasty proponent of warm pathogen disorder therapeutics, Wang Shi-Xiong, thus referred to this formula as "the master formula for damp-warmth epidemic disorders" and attributed special efficacy to it. The later Qing dynasty scholar Wu Jin-Shou attributed its composition to Ye Tian-Shi. Wu claimed to have gained access to hitherto unknown case records of the great master, which he published as Secretly Transmitted Effective Medicine in 1831. According to this text, Ye Tian-Shi composed the formula for the treatment of epidemic unseasonal disorders where the pathogenic qi was lodged in the qi level. This is indicated by a pale tongue with a white tongue coating or one that has a burned tip. If, on the other hand, the tongue is dry, crimson in color, glossy, or contracted, it indicates that the body fluids have been damaged and that the pathogen has already entered the nutritive level. Because the kind of pestilential qi that causes the disorders for which this formula is most suitable enters the body via the nose and mouth, it directly enters the qi aspect, usually at the level of the Triple Burner or the half-interior, halfexterior from which it can vent to the exterior or discharge via the Intestines. In clinical practice, it can thus be taken right at the onset of disorders that have the appropriate manifestations. Typical conditions include damp-heat infectious disorders centered on the upper burner with such symptoms as coughing, sore throat, and swollen lymph glands and tonsils, or even parotitis. It may also be used in treating dampheat stagnating in the Triple Burner characterized by persistent low-grade fever, sweating, reduced appetite, a sensation of heaviness in the body, bowel dysfunction, simultaneous bitter and sweet tastes in the mouth, and a yellow, greasy tongue coating. Although most practitioners use this formula for conditions in which both heat and dampness are present, some believe that it is more effective in treating conditions in which heat is the predominant factor. In conditions of damp-heat, the presence of either constipation or diarrhea with difficulty in passing stool are additional clues for locating the disorder. Diarrhea with difficulty in passing stool indicates that the pathogenic influences are in the Stomach or Intestines, while constipation indicates that the damp-heat is in the upper burner or the lesser yang channel.

Huo Xiang Zheng Qi San (Agastache Powder to Rectify the Qi, p. 691) CA, NCCAOM

Another type of diarrhea is that of sudden turmoil disorders or (huo luan). These are acute conditions characterized by the simultaneous onset of vomiting and diarrhea. They were first described in Discussion of Cold Damage and are associated with the penetration of wind-cold-dampness into the body. During the 19th century when cholera was first introduced into China from India, Chinese physicians sought to explain the nature of this new infectious disease by describing it as a type of sudden turmoil disorder. Some contemporary texts therefore equate the two conditions. This is not only historically wrong, but more importantly, clinically misleading, for even if 19th -century physicians called cholera a form of sudden turmoil disorder, they treated it by means of new formulas. This formula is therefore not a remedy for the biomedically-defined disease of cholera. It is suited for treating those types of sudden turmoil disorders that occur during the summertime, when dampness is the predominant aspect. The cardinal symptoms are abdominal pain, vomiting, and diarrhea, together with signs of an exterior condition.

Tong Xie Yao Fang (Important Formula for Painful Diarrhea, p. 125) NCCAOM

Another well-known modern physician, Jiao Shu-De, notes in Ten Lectures on Experiences with Formulas that he uses this formula for daybreak diarrhea when there are signs of Liver constraint such as a slightly wiry pulse or aggravation of the symptoms upon getting angry. In these cases, he combines it with Four-Miracle Pill (sl shin wan) or Aconite Accessory Root Pill to Regulate the Middle (fu zi li zhong wan). The contemporary physician and formula specialist Chen Chao-Zu goes so far as to suggest that the inclusion of Saposhnikoviae Radix (fang feng) in this formula is due to the fact that penetration by an external pathogen into the interior is the primary cause of the diarrhea treated by this formula: One must know that the cause of this presentation is externallycontracted wind-cold. It follows the lesser yang Triple Burner inward to the Intestinal passages where it lodges in the folds of the Small Intestine. Lingering for a long time without being expelled, it causes spasms that manifest as painful diarrhea. (Treatment Strategies and Formulas in Chinese Medicine) These varied interpretations indicate the usefulness of this formula in treating chronic diarrhea and in treating diarrhea in deficient patients or the elderly. The contemporary physician Wang Mian-Zhi from Beijing recommends the addition of Cimicifugae Rhizoma (sheng ma) in these cases, to assist the Spleen in raising the clear yang. For the same reason, namely, the as-yet-weak digestive system of infants and young children, he recommends it for use in pediatrics. Here, one often sees diarrhea that is yellow and watery but unaccompanied by heat symptoms. This is thought to indicate wind in Chinese medicine and so is amenable to treatment by this formula. Where cold accompanies the presentation, Wang recommends the addition of Zingiberis Rhizoma recens (sheng jiang) or Zingiberis Rhizoma preparata (pao jiang) to warm the middle.

Xiao Jian Zhong Tang (Minor Construct the Middle Decoction, p. 264) CA, NCCAOM

As with Cinnamon Twig Decoction (gui zhi tang) and its many variations, the source text does not specify which kind of Paeoniae Radix (shao yao) should be used, as there was no such differentiation during Han times. Most commentators, however, agree on the use of Paeoniae Radix alba (bai shao), citing three main reasons. First, it tonifies the blood and enriches the yin, both of which are lacking due to deficiency cold in the middle burner. Second, it harmonizes the interior and moderates the spasmodic abdominal pain that is the key symptom of one of the patterns of consumptive deficiency. Third, it softens the Liver and thereby stops the pain, providing another perspective from which the action of this formula may be viewed, namely, as Liver qi (wind-like in nature) invading a weak earth. However, where deficiency cold causes signs of blood stasis, or where constipation is a symptom, the use of Paeoniae Radix rubra (chi shao) should be considered. In Investigations of Medical Formulas, the Ming-dynasty physician Wu Kun suggested substituting Cinnamomi Cortex (rou gui), which he considered to be better at warming the interior, for Cinnamomi Ramulus (gui zhi). This suggestion was taken up by Fei Bo-Xiong in Discussion of Medical Formulas. Fei argued that Cinnamomi Cortex (rou gui) has the ability to counteract (literally 'kill' sha) wood, thus assisting Paeoniae Radix alba (bai shao) in restraining the Liver qi. Following the experience of these physicians, one may use Cinnamomi Ramulus (gui zhi) where exterior symptoms like cold limbs and fever predominate, and Cinnamomi Cortex (rou gui) where interior symptoms like abdominal pain are predominant in the presentation.

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

The case history literature also lists many instances where this formula is used to treat so-called 'strange disorders' (guai bing). These are disorders that manifest with unusual symptoms or with presentations that are difficult to match with common patterns or disorders. The successful use of this formula in treating such disorders can be traced to the pivotal physiological function of the lesser yang warp, which is confirmed by the small number of signs and symptoms needed to diagnose a pattern associated with this formula. The astute use of this formula, furthermore, can play an important role in constitutional treatment. Here it is used to maintain physical, mental, and emotional equilibrium in those with a lesser yang temperament, as outlined by the late-Qing-dynasty physician Fei Boxiong: If I possess strong defenses, I do not need to engage in battles. Still, I may have a tendency toward feeling aggrieved. [In such cases] I can also use Bupleuri Radix (chai hu) to disperse pathogens from the lesser yang and Pinelliae Rhizoma preparatum (zhi ban xia) to eliminate phlegm and move the qi in order to transform rebelliousness. This is comparable to [a city] that is safe and secure yet from time to time allows the cavalry out to [excercise their horses] in a gallop, riding out without any distinct objective and returning without having seized anything. How could [any pathogen] not melt away like ice? (Discussion of Medical Formulas) This suggests that for a constitutionally strong patient who holds grievances or stores emotions inside, it may be beneficial to occasionally give Minor Bupleurum Decoction (xiao chai hu tang) as a way of exorcizing the emotional buildup and preventing the consequences of repressed emotions. To tailor the use of this formula more specifically to its many possible indications, physicians devised many new formulas through judicious additions and substractions. Only the most famous of these are listed below. Minor Bupleurum Decoction (xiao chai hu tang) is also often paired with other classical formulas. Typical examples include the combination with Cinnamon Twig Decoction (gui zhi tang) to treat a joint disorder of the greater and lesser yang warps; with Minor Decoction [for Pathogens] Stuck in the Chest (xiao xian xiong tang) to treat cough with sticky phlegm and pain in the flanks; with Pinellia and Magnolia Bark Decoction (ban xia him po tang) to treat qi stagnation in the chest, throat, and flanks often due to emotional factors; and with Five-Ingredient Powder with Poria (wei ling san) to treat lesser yang disorders with pronounced urinary difficulty or edema. Another commonly used strategy is to adjust the relative dosage of herbs within the formula to match specific presentations. If alternating fever and chills are the key presenting problem, the dosage of Bupleuri Radix (chai hu) should be two or three times that of Scutellariae Radix (huang qin). If signs of internal heat like dryness of the throat and a bitter taste predominate, the dosage of Scutellariae Radix (huang qin) may be increased until it matches that of Bupleuri Radix (chai hu). If nausea and abdominal fullness predominate, the dosage of Pinelliae Rhizoma preparatum (zhi ban xia) should be increased accordingly.

Bai Hu Jia Ren Shen Tang (White Tiger Plus Ginseng Decoction, p. 154)

Based on his extensive clinical experience, the early modern physician Zhang Xi-Chun argued that this formula can treat damage to the true yin in the course of acute febrile disorders where yin-enriching formulas that rely on herbs like Radix Rehmanniae Glutinosae (sheng di huang) or Scrophulariae Radix (xuan shen) are ineffective. At present, thirst is taken as one of the cardinal symptoms indicating use of this formula rather than the principal formula. For this reason diabetes mellitus with Stomach fire is an important disorder for which this formula is indicated in contemporary practice.

Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction, p. 738) NCCAOM

Based on such considerations, this formula can be prescribed for any condition marked by cold in the lower burner leading to thin mucus throughout the Triple Burner. The following are examples of the wide range of conditions that can be treated in this manner. • Cardiovascular disorders: Liu Du-Zhou, the famous contemporary expert on classical formulas, uses Poria, Cinnamon Twig, Atractylodes, and Licorice Decoction (ling gul zhu gan tang) to treat a wide variety of cardiovascular disorders including coronary heart disease, pericarditis, and right heart failure. In Liu's experience, the following signs are important clinical indicators: a pale and tender tongue with a wet, slippery coating; darkish discoloration or black spots in various areas of the face, indicating water stasis; and a deep, wiry pulse. • Eye disorders: Lu Yuan-Lei, a modern classical formula expert, recommends the use of this formula with the addition of Plantaginis Semen (che qian zi) in the treatment of eye disorders characterized by redness, pain, and excessive gumminess, which he saw as arising from water blocking the Stomach. Japanese Kampo physicians, too, use the formula to treat eye disorders including inflammation, cataract, and retinopathies where there are signs of internal water stagnation. • Digestive disorders: The famous early-Qing-dynasty physician Ye Tian-Shi employed this formula to treat a wide variety of digestive disorders ranging from pain, distention, and fullness in the Stomach to diarrhea and borborygmi. For this purpose, he flexibly combined it with other formulas that warm the interior, regulate the qi, or tonify the yang. • Headaches and dizziness: Ye Tian-Shi also used this formula to treat headaches due to internal cold and yang deficiency with accumulation of turbid yin above. Modern indications include Menieres' disease, low blood pressure, and tinnitus.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

Both water and blood buildup (xu xue) can be traced back to concepts from the Discussion of Cold Damage. They are caused by pathogenic influences entering the greater yang organ, the Bladder. Water buildup occurs when the pathogenic influence enters the qi level of the Bladder and prevents the qi from carrying out its transforming function. This leads to urinary difficulty with either normal bowel movements or diarrhea. However, when the pathogenic influence enters the blood level of the Bladder, it obstructs the lower burner and causes incontinence of urine, dark stool, and acute lower abdominal pain. At this level, Peach Pit Decoction to Order the Qi (tao he cheng qi tang) is indicated (see Chapter 13).

Wei Ling Tang (Calm the ST and Poria Decoction)

Combine with Calm the Stomach Powder (ping wei san) for the treatment of the following four patterns: (1 ) watery diarrhea with stools that resemble water and are evacuated frequently; (2) edema that is more pronounced in the lower extremities; (3) dampness obstructing the middle burner characterized by focal distention in the epigastrium and abdomen, reduced appetite, and semi-liquid stools; and (4) dampness obstructing the body's exterior characterized by heaviness of the extremities. These patterns are caused by cold dampness encumbering the Spleen and the accumulation of fluids. They are usually accompanied by a pale tongue, white tongue coating, and relaxed pulse.

Ai Fu Nuan Gong Wan

Compared to the principal formula (Wen Jing Tang), this focuses more on warming the vessels and dispelling cold.

Qiang Huo Sheng Shi Tang (Notopterygium Decoction to Overcome Dampness, p. 755) NCCAOM

Composed by Li Dong-Yuan, one of the four great masters of the Jin-Yuan dynasties, this formula) embodies two important treatment strategies found in many of his other formulas and is thus representative of his style. The first is the principle that 'wind overcomes dampness.' For this purpose, Li Dong-Yuan chose a class of herbs that he and his followers refer to as 'wind herbs' (feng yao). These are herbs that promote the movement of yang qi throughout the body, are drying, and have an ascending nature. Li Dong-Yuan favored the use of these herbs because, by tonifying the ascending functions of the qi dynamic, they support the transforming and transporting functions of the middle burner, to which he attached considerable importance. This also naturally pertains to the treatment of dampness. According to Wu Kun in Investigations of Medical Formulas, "Using wind herbs to treat dampness is like wind moving above damp earth. Before the day has come to an end, the dampness will be gone." The second strategy is that of "analyzing (patterns] according to the channels, following the (manifestation] of a disorder to compose the formula:' In the present pattern, wind-dampness is located predominantly in the greater yang channel. Thus, the wind herbs employed focus on that channel. In other formulas, such as Tonify the Middle to Augment the Qi Decoction (bu zhang yi qi tang), discussed in Chapter 8, they may be used for the purpose of lifting up the Spleen and Gallbladder yang. Most practitioners use relatively small doses of this formula to produce a mild sweat. This is especially important when treating conditions such as wind-dampness, where profuse sweating could easily injure the yang and the fluids. The formula is also frequently used in treating headaches.

Zeng Ye Tang (Increase the Fluid Decoction, p. 677)

Constipation as a symptom of yang brightness disorders always has two aspects: clumping of heat and drying up of the yin fluids that moisten the Intestines and facilitate the passage of stool. Where clumping of heat is predominant, indicating the presence of a strong pathogen, one should select from one of the Order the Qi Decoctions (cheng qi tang). If the yin fluids have dried up, leading to a pattern characterized by both deficiency (the lack of fluids) and excess (the presence of hard stool in the bowels that cannot be moved), this formula is indicated. Although simple in its composition, it is still able to attack the clumped heat and prevent further injury to the yin. This is because the herbs that comprise this formula do not merely enrich the fluids, but also promote movement and are indicated for clumping. The formula's author, Wu Ju-Tong, explains: I have selected only Scrophulariae Radix (xuan shen) [to function as] chief herb. Its taste is bitter and salty. It is slightly cooling. It fortifies water to control fire. It unblocks the urine and bowels. It arouses Kidney water to rise toward the heavens. It can treat dryness of the yin fluids. These [effects] go without saying. [But the] Classic of the Materia Medica also says that it focuses on treating hot cold accummulations within the abdomen. From this one can deduce that it also is able to relieve clumping from heat. Ophiopogonis Radix (mai men dong) focuses on treating clumping of qi in the Heart and abdomen, on damage of the middle [burner] and the Womb [where] the collateral vessels of the Stomach have been cut off, on severe emaciation, and shortness of breath. Thus, it too is a substance that can tonify and moisten as well as unblock. Hence, it functions as deputy. Rehmanniae Radix (sheng di huang) also focuses on hot cold accumulations, driving out blood painful obstruction. When used with care, one selects its tonifying [properties] without [the herb] being cloying so that its [action also] extends to the collaterals.

Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction, p. 738) NCCAOM

Discussion of Cold Damage (Chapter 67) prescribes this formula for cases of injury due to cold caused by the improper use of purgatives or emetics, with such symptoms as fullness in the chest and hypochondria together with vertigo. Essentials from the Golden Cabinet recommends it for thin mucus in the epigastric region, which is resolved through the urine. This has been the purpose for which it is most frequently used by later generations of physicians. The combination of Poria (fu ling) and Cinnamomi Ramulus (gui zhi) is very effective in promoting urination (see the discussion of Five-Ingredient Powder with Poria (wu ling san) earlier in this chapter). In Chinese medicine, the term thin mucus (yin) refers both to a constellation of symptoms and a cause of disease, and is used in both a wider and more narrow sense. In its wider sense, thin mucus is a term for a disorder that can manifest through a range of different patterns, all of which are due to the accumulation of pathological fluids in one of the body cavities (the bowels, the flanks, the chest) or in the extremities. This may be due to the invasion of external pathogens or stem from the dysfunction of internal organs. In its more narrow sense, the term thin mucus defines a subcategory of phlegm. One can further differentiate between deficient and excessive types of thin mucus. This formula is indicated for the deficient type associated with yang deficiency of the Spleen and Kidneys. The excess type is characterized by severe cold in the epigastrium and abdomen and is treated with formulas like Major Construct the Middle Decoction (da jian zhang tang).

Da Qing Long Tang (Major Blue Green Dragon Decoction, p. 11)

Given the prominence of such heat signs, it may seem odd that the formula is also able to treat superficial edema, that is, water excess. This apparent contradiction is easily resolved by remembering that, from a yin/yang perspective, the excess of fluids (water) in the exterior necessarily implies a deficiency of physiological heat (fire). By mobilizing yang qi toward the exterior while simultaneously opening the pores, the formula restores a more physiological balance between water and fire, relieving the edema even if it does not directly treat the fluids. The commentators therefore agree that inducing sweating is the main goal of this formula and that unblocking the pores and interstices is the necessary means for achieving this end. Zhang Zi-He, famous for his focus on eliminating pathogens from the body, argues in Confucians' Duties to Their Parents that in a wider sense, the sweating method denotes not just the actual production of sweat at the body surface, but an "opening of the 'mysterious mansions' (xuan fu) in order to drive out pathogenic qi:' The term 'mysterious mansions' is commonly understood as referring to the sweat pores. Some physicians, however, most notably the 19th-century writer Zhou Xue-Hai, define them as points of entry and exit for the qi and body fluids that can be found throughout the tissues and organs of the body. This gives a useful perspective on how we might best understand the complex composition of this formula, especially the functions of what we regard as the two deputy herbs, Gypsum fibrosum (shi gao) and Zingiberis Rhizoma recens (sheng jaing). While Gypsum fibrosum (shi giio) is cooling, it is also acrid and sweet and thereby facilitates the movement of qi and fluids through the pores. In Essays on Medicine Esteeming the Chinese and Respecting the Western, Zhang Xi-Chun describes the action of Gypsum fibrosum (shi gao) in this formula: "Its acrid-dispersing and cooling-moistening character can help Ephedrae Herba (ma huang) and Cinnamomi Ramulus (gui zhi) thrust out the pathogen from the exterior. It is also excellent for transforming heat that has accumulated and built up in the chest into sweat, which is emitted as it follows Ephedrae Herba's (ma huang) and Cinnamomi Ramulus (gui zhi) venting of the exterior:' The relatively large dose of Zingiberis Rhizoma recens (sheng jiang), on the other hand, unblocks the flow of qi and blood throughout the entire body and facilitates the expulsion of pathogenic cold from the deepest to the most superficial regions. According to Zhang, "its pungency opens up obstructions, while its heat is able to disperse. Therefore, it is capable of warming the muscles and flesh, yet also deeply vents from the sinews and bones so as to dispel congealing, stubborn cold, causing the water to flow again as the ice disappears:'

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

Given the wide range of possible indications for this formula, it is not surprising that commentators have differed on a number of diagnostic issues. The first concerns the nature of the alternating fever and chills for which this formula is prescribed. The traditional view is that, by contrast to malarial disorders, the alternation between fever and chills seen in lesser yang patterns has no set periodicity. However, this is not specifically stated in the source text. Furthermore, the literature contains many case records that document the successful use of this formula in cases of malaria. Physicians also disagree about the precise meaning of "heat entering the blood chamber:' Cheng Wu-Ji argued that blood chamber refers to the Penetrating vessel. Ke Qin thought that it was the Liver, while Zhang Jie-Bin believed it to be the Womb. Because the source text clearly links the onset of this disorder to blood loss during menstruation or birth, that is, from the Womb, most modern writers follow Zhang Jie-Bin's interpretation. The Womb is linked to the terminal yin, which in turn enjoys an interior/exterior relationship with the lesser yang. Using this formula can thus create an exit route for pathogenic heat from an organ that does not have its own link to the exterior.

Zhu Ling Tang (Polyporus Decoction, p. 731) CA, NCCAOM

Given the wide spectrum of potential applications, the key clinical markers for this formula can be summarized as follows: 1. Reduced urination is more a matter of reduced frequency, urinary difficulty, or incomplete voiding. The amount of urine itself is less significant of an indicator. 2. Signs of water excess such as edema, fullness, and resistance to pressure in the lower abdomen, diarrhea, and a white (but dry) tongue coating. Because the edema results from clumping of heat and water in the lower burner rather than from excess water flooding the body, it generally does not affect the respiratory system. 3. Signs that heat has damaged the yin, such as a darkish red tongue, insomnia, and irritability.

Zhu Ling Tang (Polyporus Decoction, p. 731) CA, NCCAOM

Given this particular combination of excess and deficiency, the use of this formula was extended by the late-Qing-dynasty physician Tang Zong-Hai to the treatment of phlegm in yin deficient patients. Tang explained his reasoning in Discussion of Blood Patterns: This formula is specific for enriching the yin and promoting urination. It is effective in all cases of Kidney channel yin deficiency with water flooding that becomes phlegm. It employs Asini Corii Colla (e jiao) to moisten dryness and Talcum (hua shi) to clear heat. Combining these enriching and downward directing substances with all the other herbs [in the formula] accounts for its efficacy in eliminating phlegm. The root of phlegm is in the Kidneys. One controls the Lungs to treat its manifestations. One treats the Kidneys to treat its root.

Xiao Qing Long Tang (Minor Blue Green Dragon Decoction, p. 21) NCCAOM

However, Essentials from the Golden Cabinet explicitly uses this formula for problems of water metabolism that are not associated with exterior disorders. These include seeping thin mucus (yi yin), coughing with rebellious qi that makes it impossible for the patient to lie down, and vomiting of frothy saliva during pregnancy. The efficacy of the formula in these cases is due to its ability to remove constraints to qi circulation that impede the transformation and elimination of fluids. Sometimes the image of a teapot is used to illustrate this function. In order for tea to pour from its spout, a teapot needs a second hole in the lid that allows air in as liquid flows out. This formula opens both holes (the pores in the skin and the urinary passageways) when they have become blocked due to either external wind-cold or insufficient penetration of yang qi from the gate of vitality to the body's surface. This formula is thus an early example of the importance attached to regulating the qi mechanism in treating disorders of water metabolism. Here, this is partly achieved by regulating the ascending and descending aspects of the qi dynamic, primarily through the synergism between Cinnamomi Ramulus (gui zhi) and Pinelliae Rhizoma (ban xia). The latter herb, focused on the Stomach, eliminates water and dampness, both by drying and dispersing and through its ability to direct qi downward. The former herb, on the other hand, facilitates the ascending of qi and transformation of fluids via the Liver, as discussed by Tang Zong-Hai in Discussion of Blood Patterns: Cinnamomi Ramulus (gui zhi) is a Liver herb that transforms water. The Liver is the child of the Kidneys. When in a state of excess, the child drains the mother. Furthermore, the Liver also governs dredging and draining and thus has the ability to transform water. [The herb J also tonifies the Heart. In case of deficiency, one tonifies the mother. The Liver is the mother of Heart fire. Furthermore, Cinnamomi Ramulus (gui zhi) is red and enters the Heart [directly]. To promote sweating, one can therefore also use Cinnamomi Ramulus (gui zhi). [In this case], one borrows the warmth of wood qi in order to disperse and facilitate dissemination toward the exterior. Just as important is the formula's focus on ensuring unhindered entering and exiting. This is why acrid, warm herbs that promote exiting are combined with sour, astringent herbs that facilitate holding and entering. Paeoniae Radix alba (bai shao) and Schisandrae Fructus (wu wei zi) thereby contribute actively to the effect of the formula, rather than merely counteracting the potential side effects of the main herbs.

Ge Gen Tang (Kudzu Decoction, p. 19) NCCAOM

In Discussion of Cold Damage (paragraph 32) it is noted that this formula can also be used for a simultaneous greater yang and yang brightness-warp disorder with diarrhea. This is usually explained by the formula's ability to help the Stomach qi rise while releasing the exterior. In Essentials from the Golden Cabinet this formula is indicated for a greater yang-warp disorder in the absence of sweating and scanty urination. This is a condition of exterior excess in a person with deficient fluids. In this case, the qi pours upward into the chest and prevents one from opening the mouth to speak. This formula may also be used in treating the transitional stage between acute and chronic rhinitis or sinusitis characterized by mucosal swelling, congestion, and sensitivity to dust and cold drafts. For this reason, some practitioners use the formula as a foundation in formulas that treat allergic rhinitis. Deng Shao-Xian, a prominent modern physician from Chengdu, uses this decoction for chronic pediatric diarrhea with considerable success. It is also very effective for acute stiff neck

Li Zhong Wan (Regulate the Middle Pill, p. 257) CA, NCCAOM

In clinical practice, therefore, the following signs and symptoms are key clinical markers for use of this formula: • Abdominal distention or pain in patients with a soft and lax abdomen that is not relieved by belching or the passing of wind • Pain that is mild and chronic rather than acute and relieved by warmth or warming foods • Abnormal stools that tend to be soft and loose but can also be hard if untransformed fluids are directly eliminated via the bladder. Since its first listing in Discussion of Cold Damage, subsequent generations of physicians have used this formula as the foundation for a large number of new formulas that extend its range. These include pox and rashes (based on its ability to treat the root of deficiency wind), blood stasis-type abdominal pain (which develops against a background of cold and blood deficiency), and lower back pain (caused by blood deficiency due to middle burner cold). Depending on the type of disorder treated, the formula is prescribed as a pill (more suitable for patterns characterized by mild symptoms like spitting of thin saliva) or as a decoction (indicated for patterns that are more acute, such as sudden turmoil disorder or bleeding).

Da Qing Long Tang (Major Blue Green Dragon Decoction, p. 11)

In practice, focusing on this ability to unblock the qi dynamic is thus key to the successful use of this formula. Paragraph 39 of Discussion of Cold Damage is explicit in distinguishing a pattern characterized by a floating and relaxed pulse, and a sensation of heaviness in the body that sometimes becomes better and sometimes worse and that responds to this formula, from a similar presentation in lesser yin stage disorders. In both cases, the circulation of yang qi through the body is impeded by the presence of yin excess. This is experienced as heaviness of the body, accompanied by sensations of heat, chills, and an absence of sweating. However, because in lesser yin patterns the yang qi is deficient, the patient will be primarily cold, and any heat signs will be due to weak yang floating toward the surface. In the present pattern, however, the yang qi is strong, and the constraint-and thus the irritability and restlessness-are pronounced. Historically, this formula has been enormously influential in establishing a strategy for releasing the exterior while simultaneously clearing heat from the interior. Formulas like Nine-Herb Decoction with Notopterygium (jiu wei qiang huo tang) and Saposhnikovia Powder that Sagely Unblocks (fang feng tong sheng san) employ new herbs and treat new patterns. Their authors, the famous Jin-Yuan master physicians Zhang Yuan-Su and Liu Wan-Su, can be seen as honoring Zhang Zhong-Jing by following the path he blazed.

Xiao Qing Long Tang (Minor Blue Green Dragon Decoction, p. 21) NCCAOM

In summary, this is one formula that should be considered for any condition characterized by an excess of water that cannot be transformed by the body's yang qi and that, in turn, constrains the qi dynamic. In clinical practice, this will most often involve conditions characterized by coughing and wheezing, although it may extend to other symptoms of water excess such as nausea, diarrhea, or edema. However, given the harsh nature of the formula, it is important to be certain that its use is, in fact, indicated in a particular case. Paying attention to the following four indicators will greatly assist in making the correct diagnosis. 1. Complexion: Cold, thin mucus obstructing the dispersion of yang to the exterior is often reflected in some degree of puffiness, especially around the eyes, but also the occurrence of dark spots, indicating constraint due to cold, at the temples, under the eyes, on the cheeks, or at the neck. 2. Pulse: Textbooks describe the typical pulse accompanying this pattern as wiry (indicating constraint due to thin mucus), or floating and tight (indicating cold fettering the exterior). In practice, however, the pulse can also be deep and slow, or frail, at the distal or proximal positions, indicating that the yang qi cannot penetrate to the exterior because it is constrained by yin fluids. 3. Tongue: The typical tongue in this pattern will be wet with a slippery white coating. The tongue body itself will not be abnormal, unlike patterns marked by dampness due to Kidney or Spleen deficiency. 4. Secretions: Visible mucus in this pattern will be thin, watery, and bubbly. Sputum expectorated from the Lungs will resemble egg white in consistency and be clear and transparent. Furthermore, once the acute symptoms have abated, it is advisable to switch to a milder formula, like those built around the combination of Cinnamomi Ramulus (gui zhi) and Poria (fu ling), in order to promote the transformation of qi and water.

Jiu Wei Qiang Huo Tang (Nine-Herb Decoction with Notopterygium, p. 24)

Influential commentators like Xu Da-Chun, Wang XuGao, and Fei Bo-Xiong argue, however, that the use of such a thick and cloying herb is only necessary if the heat is severe and the dryness is pronounced. In all other cases, they suggest the use of either Angelicae sinensis Radix (dang gui) or Radix Paeoniae (shao yao). When treating patients with a disposition toward damp-phlegm retention, modern practitioners go one step further and remove Radix Rehmanniae Glutinosae (sheng dl huang), substituting herbs that move the qi and transform dampness, such as Magnoliae officinalis Cortex (hou po) and Citri reticulatae Pericarpium (chen pi). The combination of acrid, warm herbs thought to have an ascending nature with bitter, cold herbs that direct qi downward must also be viewed against the increased importance that the Jin-Yuan innovators attached to the qi dynamic. These physicians reasoned that herbs like Notopterygii Rhizoma seu Radix (qiang huo), Saposhnikoviae Radix (fang feng), or Atractylodis Rhizoma (cang zhu) raise the clear qi, a dynamic that not only corresponds to that of the Spleen, but also to that of the lesser yang, and, by implication, to spring. This ascending movement dries dampness in the same manner that the warm spring winds dry the earth. It is for this reason that these herbs are also known as 'wind herbs' (feng yao).

Ge Gen Huang Qin Huang Lian Tang (Kudzu, Scutellaria and Coptis Decoction, p. 292) NCCAOM

Irrespective of the prior treatment history, the use of this formula has been expanded to include any early-stage dysenteric enteric disorder characterized by fever, foul-smelling stools, a burning sensation in the anus, a red tongue with a yellow coating, and a rapid pulse. This condition is identified as lower burner damp-heat with lingering exterior symptoms. A variation of the formula Patchouli/ Agastache Powder to Rectify the Qi (huo xiang zheng qi san) can be used if the heat is not severe. The use of this formula was further expanded during the late Qing dynasty by Lu Mao-Xiu to cover yang brightness warm pathogen disorders and, in particular, the occurrence of sand papules (sha zhen). In Medical Texts from Bettering the World Studio, Lu argued that this formula was "the essential method for treating sand papules" because of its ability to simultaneously resolve the exterior and drain heat from the interior without overemphasizing either aspect. In contemporary clinical practice, the formula is also used for conditions characterized by subjective sensations of heat such as periomenopausal hot flushes or hypertension. Another usage is prolapse of the anus where the uplifting properties of Puerariae Radix (ge gen) are exploited to help the qi in the greater yin to ascend. In contrast to Tonify the Middle to Augment the Qi Decoction (bu zhang yi qi tang), which is used for deficiency conditions, this formula is appropriate where prolapse occurs as a result of heat excess diarrhea.

Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephala and Licorice Decoction, p. 738) NCCAOM

It is obvious from the above that this formula treats a pattern and not a disease and that clearly defining this pattern is key to its successful use in the clinic. Based on an analysis of the literature, the following clinical markers will facilitate correctly identifying this pattern: • Dizziness or spots in front of the eyes when getting up • Hot flushes, palpitations, tachycardia, nervousness (indicating that the yang qi does not penetrate into the excess yin water) • Cold abdomen or splashing sounds in the Stomach on palpation (indicating cold in the Stomach and accumulation of thin mucus); or large areas of coldness on the back or along the spine (indicating lack of yang qi in the interior) • Pale tongue with a slippery, white coating (indicating cold and water) seen together with a submerged and wiry pulse (indicating stagnation of fluids in the interior) • Periodic nature of the symptomatology, characterized by periods of acute ill-health alternating with others when few or no symptoms are present; symptoms will be aggravated by exhaustion, fatigue, nervous tension, or the contraction of external pathogens, that is, periods when the yang qi has been depleted. • Visible signs of thin mucus such as increased urination, edema, coughing of thin mucus, or excess saliva.

Da Cheng Qi Tang (Major Order the Qi Decoction, p. 63) CA, NCCAOM

Many commentators furthermore suggest that although the formula orders the qi, its most important purpose is to preserve the fluids, which are threatened by the severe heat in the interior. Yang is generated from yin. Thus, if heat is eliminated and the fluids are preserved, qi will automatically return. This logic allows a physician to forcefully drain qi in the process of purgation without, over the long run, damaging the body's normal qi. The alternative, avoiding purgation for fear of damaging the qi, would in fact end up doing much more harm to the qi. Still, one must take recourse to purgation only when the circumstances demand such a course of action. The following basic rules, and the contraindications listed below, provide clinicians with clear guidelines. First, it is important to distinguish the principal pattern for which this formula is indicated from that of a yang brightness channel or White Tiger Decoction (bai hu tang) pattern, discussed in Chapter 4. In such a pattern, the momentum of the heat is to move outward, and it is better to follow rather than fight this movement. Thus, the heat should be cleared rather than purged. One of the most important markers for making this differentiation is the relationship between pulse and abdominal symptoms. In a White Tiger Decoction (bai hu tang) pattern, the heat has not acquired form and thus follows its natural tendency to expand outward. This is reflected in a flooding pulse. In all of the Order the Qi Decoction (cheng qi tang) patterns, the heat binds with matter in the interior and thus acquires form. This is reflected in a pulse that is submerged, excessive, and forceful. If the normal qi is completely blocked, the pulse may become confined or even disappear altogether. In cold damage patterns, where transformation of cold into heat is slow and the main objective is to prevent damage to the yang qi, it is considered essential to wait until the pulse becomes submerged before using a purging formula. In warm pathogen disorders, where the main consideration is to prevent damage to the yin fluids, one should consider using a purgative formula as soon as abdominal signs indicate that heat is acquiring form, even if the pulse is still flooding. For maximum effectiveness, it is also important to adhere to the directions for preparation and only decoct Rhei Radix et Rhizoma (da huang) for a short period of time. Ke Qin notes that when it is used "fresh, its [own] qi is fast and therefore it moves the qi. When it is decocted, its qi is blunted and it becomes balanced and moderate."

Xiao Yao Wan (Rambling Powder, p. 120) CA, NCCAOM

Many different explanations for the formula's name can be found in the literature, besides that outlined above. Wang Zi-Jie, a teacher of Ye Tian-Shi, notes in Selected Annotations to Ancient Formulas from the Garden of Crimson Snow: According to the [1st-century dictionary] Elucidations of the Signs and Explications of the Graphs, the characters xiao yao are interchangeable with [their homonyms] ~ill (to reduce) and .t£ (to shake). The commentary to the [first chapter of] Zhuang Zi, "Rambling Without a Destination;' states: 'When the sun rises it reduces the ice. Even though it is consumed, its essential nature is not exhausted. When a boat moves it shakes the water. Even though it is moved, its inner nature is not damaged.' Transferred to the domain of medicine [it implies that this formula] even as it reduces and disperses qi constraint and shakes and moves blood constraint, it never damages the normal qi.

Xiao Yao Wan (Rambling Powder, p. 120) CA, NCCAOM

Not surprisingly, some commentators, like the contemporary physician and formula expert Wang Mian-Zhi, thus argue that if constraint arises from Liver deficiency, then Angelicae sinensis Radix (dang gui) and Paeoniae Radix alba (bdi shao) rather than Bupleuri Radix (chai hu) should be regarded as the formula's chief herbs. Furthermore, the manifestations of Liver constraint are seen as closely intertwined with emotional problems. Linking the Liver's governance of blood to the essential nature of female physiology, physicians throughout the history of Chinese medicine have maintained that women are specifically prone to this type of disorder. The discussion of the formula in Discussion of Medical Formulas by the late Qing-dynasty physician Fei Bo-Xiong, an expert in the treatment of emotional disorders, is typical: Rambling Powder (xiao yao san) employs the strategies of thrusting out Liver wood and disseminating Gallbladder qi within [the more fundamental approach] of regulating nutritive [ qi] and supporting earth. It is an especially good formula for resolving constraint. The Liver is the strongest of the five yin organs. Among the seasons, it corresponds to the spring, among the five phases, to wood. It embodies the dynamic of development and growth. Whenever this [dynamic] is constrained, a person tends to become angry and tense and unable to return [to a state of tranquility]. When fire flourishes, it overcontrols metal, when wood flourishes, it overcontrols earth. Because it affects other organs, it is appropriate to put [this situation] in order .... If one adds the two herbs Salviae miltiorrhizae Radix (dan shen) and Cyperi Rhizoma (xiang fu) in order to regulate the menses [the effects of this formula] will be even more marvelous. This is because women are far more prone to constraint. Despite such gender-based analysis, in contemporary practice, this formula can be assumed to be as useful in the treatment of men as it is in the treatment of women. The manner in which the potential indications of this formula have been extended in modern China reflect this insight.

Zhen Wu Tang (True Warrior Decoction, p. 744) CA, NCCAOM

One of the most useful guides to the many patterns for which this formula can be used is provided by the contemporary physician Chen Chao-Zu. In Treatment Strategies and Formulas in Chinese Medicine, Chen groups these patterns under eight headings: 1. Lesser yin warp yang deficiency with obstruction and stagnation of phlegm fluids and water-dampness in the lower burner, Kidneys, or Bladder. This may manifest as urinary difficulty or obstruction, tidal flushing of the genitals by dampness, water buildup leading to bulging disorder, clear, watery discharges, seminal emissions, impotence, or gradual weight gain. 2. Stagnation and lingering of excess fluids in the exterior, manifesting as aversion to cold, aches and pains in the body and extremities, or edema. If symptoms of yang deficiency predominate and the exterior is not secured, there will be sweating, the person will easily catch colds and infections, be prone to allergies, or wind erysipelas and dormant papules. 3. Joint disorders of the Kidneys and Spleen, where the ascending and descending functions are disordered. This can manifest as abdominal fullness or pain, nausea, vomiting, diarrhea, or constipation. 4. Clogging and stagnation of the Liver channel manifesting as flank pain, dizziness and vertigo, twitching of the muscles and sinews, atrophy or aching of the muscles, or hiccup. 5. Water qi intimidating the Heart, manifesting as chest painful obstruction, palpitations, and disordered mental and emotional functions. 6. Water flooding the upper source, manifesting as wheezing and coughing. 7. Phlegm fluids and water-dampness attacking the clear yang above, clogging and obstructing the sensory orifices. This may manifest as lightheadedness, a distending or heavy sensation in the head, headaches, hair loss, impaired memory, nasal obstruction with clear nasal mucus, incessant sneezing, impaired visual acuity, or swelling and pain of teeth or gums. 8. Impairment of qi transformation leading to dampness stagnating in the vessels and blood vessels. This may manifest as a husky voice, a sensation of something being stuck in the throat, a puffy tongue body, a greasy white tongue coating, and a pulse that has no fixed form or shape.

Da Huang Fu Zi Tang (Rhubarb and Prepared Aconite Decoction, p. 71)

Other commentators, such as the compilers of the Golden Mirror of the Medical Tradition, argue that the primary disease dynamic is cold in the Spleen and Liver. Unlike the source text, they therefore regard the main symptoms to include abdominal fullness and pain (Spleen) as well as stubborn pain in the ribs (Liver). Accordingly, they interpret the dynamic of the formula differently. They suggest that Rhei Radix et Rhizoma (da huang) is used to drain accumulation from the Spleen and abdomen, and Asari Radix et Rhizoma (xi xin) to relieve pain in the Liver and ribs. While they do not specify the precise dynamic of the Asari Radix et Rhizoma (xi xin) action, one can presume it works by warm dispersal of water and dampness to open the collaterals.

Xiao Chai Hu Tang (Minor Bupleurum Decoction, p. 104) CA, NCCAOM

Over the centuries, physicians have extended the range of disorders for which this formula is indicated even further. Its use in modern practice can be grouped into six broad categories: 1. Febrile disorders with alternating fever and chills 2. Digestive disorders that present with signs of stagnation or clumping in the Liver and Gallbladder channels, or where loss of the Stomach's downward-directing function is accompanied by a wiry pulse 3. Gynecological disorders that match the presentations of heat entering the blood chamber where signs of blood stasis are accompanied by alternating chills and heat flushes 4. Urogenital disorders where signs of heat or inflammation are accompanied by qi stagnation 5. Miscellaneous disorders with a clear relationship to the lesser yang channels or related patterns, such as inflamed lymph glands in the neck or armpits, thyroid enlargement, hypertension, or palpitations 6. Nervous system and emotional disorders with a lesser yang presentation including insomnia, anxiety, headache, and nerve pain.

Dao Chi San (Guide out the Red Powder, p. 195) CA, NCCAOM

Over time, the original indication of this formula was expanded by successive generations of physicians. The 11thcentury Formulary of the Pharmacy Service for Benefiting the People in the Taiping Era, for instance, lists its indications as internal heat in the Heart channel in both children and adults with irritability, a stifling sensation in the chest, and confusion, as well as urinary problems due to heat transferred from the Heart to the Small Intestine. The 18th-century Golden Mirror of the Medical Tradition prescribes it for mouth ulcers and sores, pain in the throat, acute wheezing due to Heart heat punishing the Lungs, and urinary problems during pregnancy. The early modern physician Zhang Shan-Lei added Scutellariae Radix (huang qin) to the formula and prescribed it for clearing heat from the Lungs.

Li Zhong Wan (Regulate the Middle Pill, p. 257) CA, NCCAOM

Physicians have argued over the nature of the chief herb in this formula. The Song dynasty commentator Cheng Wu-Ji contended that it was Ginseng Radix (ren shen) because of its ability to tonify the middle burner. Others, like the modern physician Cai Lu-Xin, argue that the chief herb is Zingiberis Rhizoma (gan jiang) because of its ability to warm and support the yang. In practice, most physicians adopt a flexible approach that focuses on the interaction between the various ingredients of the formula, adjusting their relative dosage according to the presenting symptoms.

Xie Bai San (Drain the White Powder)

Physicians have long argued whether this formula can be used when a pathogenic factor is present in the exterior. Symptom, Cause, Pulse, and Treatment and the Golden Mirror of the Medical Tradition prescribe modifications of this formula to treat patterns where exterior wind-cold is tying the protective qi in the exterior. Systematic Differentiation of Warm Pathogen Diseases, on the other hand, contains a famous essay entitled "On Why Drain the White Powder (xie bai san) Cannot Be Used Rashly" in which its author, Wu Ju-Tong, explains: Throughout the ages the commentators on this formula only discuss its merits but do not [appear to] know about its drawbacks .... This formula is excellent for treating cough, ascending qi, and fever from deficiency in the wake of feverish disorders or pox in children, if no external pathogen remains but the true original [qi] is unable to return to its source [in the gate of vitality]. However, if one uses Mori Cortex (sang bai pi) and Lycii Cortex (di gu pi) where wind-cold or wind-warmth truly are in overabundance, or if one adds either of these herbs to other formulas [in the treatment of such disorders], it is like pouring oil into a soup. They will plug [the exterior and produce] clumping, so that [the disorder] cannot be resolved. The early modern physician Zhang Shan-Lei forefully repeated this warning, stating that unless there exist clear indications, use of this formula without significant modification is best avoided until all external pathogens have been cleared.

Dao Chi San (Guide out the Red Powder, p. 195) CA, NCCAOM

Since it was first published, the formula has been repeatedly modified. The medical literature therefore contains many formulas by the same name but with different ingredients. Additions to the original formula can be organized into three main groups: 1. Herbs that clear the Heart and drain fire, such as Bubali Cornu (shui niu jiao), Forsythiae Fructus (lian qiao), Gardeniae Fructus (zhi zi), and Scutellariae Radix (huang qin) 2. Herbs that clear heat and promote urination, such as Plantaginis Semen (che qian zi), Junci Medulla (deng xin cao), Imperatae Rhizoma (bai mao gen), and Poria (fu ling) 3. Herbs that nourish the yin and augment the qi, such as Ophiopogonis Radix (mai men dong) and Ginseng Radix (ren shen)

Zhen Wu Tang (True Warrior Decoction, p. 744) CA, NCCAOM

Some commentators have questioned the use of Paeoniae Radix (shao yao) in this formula, which is generally taken to be Paeoniae Radix alba (bai shao). They argue that in patients with yang deficiency and the overflow of water, the sour, binding properties of Paeoniae Radix alba (bai shao) might further aggravate the retention of water. Those who support its inclusion in the formula refer to three important properties of the herb. First, several ancient texts, including Divine Husbandman's Classic of the Materia Medica, state that Paeoniae Radix (shao yao) is able to promote urination and move water. This property is enhanced when it is combined with Poria (fu ling) and Atractylodis macrocephalae Rhizoma (bai zhu). Second, Paeoniae Radix (shao yao) augments the yin, softens the Liver, and moderates abdominal pain. The Liver is responsible for dredging and draining, which includes keeping open the waterways. Abdominal pain is a symptom in the formula's patterns. Third, while Paeoniae Radix (shao yao) prevents injury to the yin by checking the drying action of the herbs that drain dampness, its own binding nature is moderated by the other herbs in this formula. Rather than causing the pathogenic water to accumulate or stagnate, these synergistic interactions elevate Paeoniae Radix (shao yao) to an essential ingredient. Moreover, because this formula is also indicated for cases in which the protective yang qi is depleted by excessive sweating, Paeoniae Radix alba (bai shao) serves to restrain the sweating in the same manner as it does in Cinnamon Twig Decoction (gui zhi tang). Other commentators question why Zingiberis Rhizoma recens (sheng jiang), rather than the more heating Zingiberis Rhizoma (gan jiang), is used in a formula intended to mobilize the yang. They point to the combination of Aconiti Radix lateralis preparata (zhi fu zi) and Zingiberis Rhizoma (gan jiang) in Frigid Extremities Decoction (si ni tang), which is the flagship formula for lesser yin patterns. However, whereas the intention of that formula is to mobilize the yang in the channels for which a heating substance is preferable, the focus of this formula is on moving excessive water qi out of the body. For this purposes, the more acrid and moving (but less heating) Zingiberis Rhizoma recens (sheng jiang) is more appropriate. In fact, Zingiberis Rhizoma recens (sheng jiang) is used in many of Zhang Zhong-Jing's formulas whenever this is the objective.

Dang Gui Liu Huang Tang (Tangkuei and Six Yellow Decoction, p. 218) CA, NCCAOM

Some commentators, such as the modern physician Zhang Nian-Shun, go even further and argue that the formula was intended for night sweats associated with deficient protective qi coupled with vigorous fire that has injured the yin. Besides night sweats, this presentation includes fever, a red face, irritability, dark-yellow or red urine, a red tongue with a coating, and a flooding, rapid pulse. In this interpretation, because the deficiency of the protective qi is primary, Astragali Radix (huang qi) is regarded as the chief herb, and because the deficiency of yin is due to vigorous fire, the heat-clearing herbs are regarded as deputies and the yin tonics as assistants. Given that the actions of this formula in nourishing the yin and blood while draining fire from the three burners are rather strong, it is best used in cases where the middle qi has not been injured. It can be utilized in treating many types of disorders with night sweats including Lung consumption, steaming bone disorder, the aftermath of a severe febrile disease, and chronic nosebleeds.

Ji Chuan Jian (Benefit the River Decoction, p. 84) NCCAOM

The analysis of the formula's indications and actions above follows that of modern Chinese textbooks. Given the emphasis on organ systems of functions in contemporary Chinese medicine, this analysis defines the formula as primarily strengthening the Kidneys. However, neither the source text nor later premodern commentators view this as a Kidney formula. A more thorough understanding of its actions, indications, and functions can be gained by taking into account these other interpretations. In the source text, Zhang Jie-Bin simply notes that constipation due to deficiency should not be treated with harsh purgatives like Natrii Sulfas (mang xiao) and Rhei Radix et Rhizoma (da huang). He then says: "As the general momentum [of deficiency disorders] cannot but have a lack of unobstructed passage, it is appropriate to govern [such a disorder] by means of the present [strategy]. This is to employ unblocking within a tonifying formula." Clearly, Zhang Jie-Bin's main concern is the process of qi transformation as a whole and not the function of individual organs. In Revised Popular Guide to the Discussion of Cold Damage, He Lian-Chen underlines this perspective by focusing on the complementary roles of the Kidneys and Liver, substance (yin) and function (qi): this formula mainly emphasizes the Liver and Kidneys and uses [the fact that] the Kidneys govern urination and defecation. Accordingly, it uses Cistanches Herba (rou cong rong) and Achyranthis Radix (niu xi) as chiefs. They enrich the Kidney yin to unblock the passage of stool. The Liver governs dredging and draining. Accordingly, it uses Angelicae sinensis Radix (dang gui) and Aurantii Fructus (zhi ke) as deputies. The first is acrid and moistening [and focuses on] Liver yin. The second is bitter and draining [and focuses on] Liver qi. The marvel [of the formula's composition, however, lies in its combination of] Cimicifugae Rhizoma (sheng ma), which raises the clear qi to contribute to Spleen [qi transformation], and Alismatis Rhizoma (ze xie), which directs the turbid qi downward to contribute to the Bladder [ qi transformation]. They assist Cistanches Herba (rou cong r6ng) in realizing its power of facilitating [passage of the stools] by means of moistening. Precisely because this formula uses tonification as a means of facilitating movement, it is listed in almost all fomularies as a formula that moistens the Intestines and not as one that simultaneously tonifies and purges. The formula can thus be used to treat constipation that arises from Liver blood problems as well as Kidney qi deficiency, or where the essences are too depleted to enable bowel movement. Zhang Jie-Bin also suggested a number of modifications, which are listed below.

Da Huang Fu Zi Tang (Rhubarb and Prepared Aconite Decoction, p. 71)

The apparent disagreement among commentators regarding all aspects of the formula's indication and functions-of which the above is but a small selection-should not distract us from the underlying consensus: that the formula opens the qi dynamic, which is obstructed by cold; that this obstruction is severe and involves binding of qi and fluids or blood; that obstruction of the qi dynamic in the lower burner, the dwelling place of Liver and Kidneys, often manifests with rebellion; and that the bowels are used as a pathway to conduct the pathogens out of the body. This allows us to understand the many directions in which use of this formula has been developed over subsequent centuries. Comprehensive Medicine According to Master Zhang recommends it for "jaundice with slight sweating of the forehead, [unobstructed] urination, black stools, and pain in the lower abdomen extending to the back:' Lu Yuan-Lei, in Modern Explanation of the Golden Cabinet, uses it to treat cold-type bulging disorders, gripping pain in the chest and abdomen, swelling of the testicles, occasional water sounds in the abdomen, and severe aversion to cold. More recently, the formula has become a standard in the treatment of uremia, where it is frequently applied as an enema with the intention of conducting toxins out of the body. This can be seen as an extrapolation of the disease dynamic described by Cao Ying Fu and others above.

Ma Zi Ren Wan (Hemp Seed Pill, p. 81) CA, NCCAOM

The definition of the 'Spleen bind' pattern in paragraph 247 of Discussion of Cold Damage is extremely brief: "When the dorsal pedis pulse is floating and choppy along with frequent urination and hard bowel movements, the Spleen is bound. This formula masters it:' Given the limited nature of this passage, successive generations of commentators have added their own interpretations. The earliest commentator on this book was Cheng Wu Ji. In Discussion Illuminating the Principles of Cold Damage, he defined the word binding (yue) as "being bound by a contract or pact" (jie yue) or "being controlled or dominated" (yue shu). He went on to say that here: The Stomach is strong and the Spleen is weak. [As the Spleen] governs the [movement of] fluids, they are not distributed to the four extremities but transported to the Bladder. As a consequence, urination is frequent and the stool is hard. Therefore, one says that the Spleen [in such a case] is bound. While this clearly states that the pathology is one of the problems with fluid transportation due to Stomach excess, his unfortunate insertion of the notion of a weak Spleen caused much confusion among later writers. Some physicians-foremost among them Zhu Dan-Xi-took this to mean that dry heat had damaged the Spleen, or even that blood or yin had become deficient. As a result, some physicians have prescribed this formula for the treatment of chronic constipation in the weak and elderly. However, the emphasis of the formula is clearly on removing excess. Even the moistening herbs in the formula are primarily intended to move stagnation and not to enrich yin or generate fluids. In Writings on the Esteemed Discussion, the Ming-dynasty physician Yu Chang therefore severely criticized this mistake: Should not a weak Spleen be tonified? Why then does this formula contain herbs contrary [to this intention]like Rhei Radix et Rhizoma (da huang), Aurantii Fructus immaturus (zhi shi), and Magnoliae officinal is Cortex (hou po)? ... [Zhang] Zhong-Jing said 'strong Stomach.' The original text never mentioned a 'weak Spleen.' The fact is that when [the original] talks about a strong Stomach, what it really means by strong is that the Spleen is strong. To bind [means] to economize. If the Spleen qi is excessively strong, it will economize by expelling the food taken in by the Stomach over three to five days in only one or two pellets. Altogether, [this pattern] is one where earth is excessively dry causing the fluids within the Stomach and Intestines to become daily more dessicated, hence the stools become difficult [to expel] . If the Spleen qi were weak, this would cause diarrhea. What could be the reason for making such stools difficult to expel?

Xiao Yao Wan (Rambling Powder, p. 120) CA, NCCAOM

The famous 20th-century physician Yue Mei-Zhong recommended Augmented Rambling Powder (jia wei xiao yao san) with Prunellae Spica (xia ku cao), Taxilli Herba (sang ji sheng), and Ligustri lucidi Fructus (nu zhen zi) for treating hypertension. A modification of this formula based on Augmented Rambling Powder (jia wei xiao yao san) with Chrysanthemi Flos (ju hua), Lycii Fructus (gou qi zi), and Acori tatarinowii Rhizoma (shi chang pu) was devised by Wei Wen-Gui to treat various ophthalmological disorders including glaucoma, optic nerve atrophy, acute retrobulbar neuritis, cortical blindness, and central retinitis. Another important indication for its use in contemporary practice is the formula's ability to vent pathogens that invade the body against a background of deficiency. The 17th century Comprehensive Medicine According to Master Zhang states that Rambling Powder (xiao yao san) is effective for spontaneous sweating arising from Liver deficiency. This type of pathology implies a disharmony between nutritive and protective qi, a pathology that frequently underpins allergies, recurrent infections, and the inability to vent lingering pathogens. The modern physician Zhang Yao-Qing from Shanghai suggests that in blood deficient patients where a pathogen remains in the exterior, Menthae haplocalycis Herba (bo he) and Zingiberis Rhizoma recens (sheng jiang) should be made the chief herbs through an appropriate adjustment in dosage. If the pathogen penetrates into the lesser yang, the dosage of Bupleuri Radix (chai hu) may also be increased. Where blood deficiency is accompanied by internal heat, Menthae haplocalycis Herba (bo he) and Glycyrrhizae Radix (gan cao) become the chief ingredients.

Qing fei yin (clear the lungs decoction)

The fire here can be anything from a chronic Liver fire pattern to a secondary pathogen, as long as it damages the Lung yin. Often, the primary and secondary sources of fire coexist. For example, a pattern of chronic Liver stagnation may lead to Liver fire directly affecting the Lungs and simultaneously affect the Spleen such that it can no longer properly disseminate the fluids. Regardless of the cause, over time, damage to the Lung yin reduces the Lungs' ability to disseminate the qi and move the fluids. Together with the heat, this will cause phlegm. Furthermore, the obstructing nature of constrained Lung qi compounded by the presence of fire in its substantial (phlegm) and insubstantial forms, results in symptoms such as hoarseness and incessant cough. If the fire is extreme, it can also manifest as throat lesions.

Sang Xing Tang (Mulberry Leaf and Apricot Kernel Decoction, p. 665) NCCAOM

The important indications for this formula include a dry, hacking cough, a thin, dry, white tongue coating, and a floating, rapid pulse. It may also be used for conditions at this level that affect the collaterals of the Lungs with coughing of blood and for the treatment of respiratory problems caused by working in dry environments. In composing this formula, Wu Ju-Tong was influenced by Yu Chang's principles of treating dryness by means of sweet, moistening, and slight cooling, which is discussed in more detail in the entry for Clear Dryness and Rescue the Lungs Decoction (qing zao jiu fei tang), as well as by Ye Tian-Shi's treatment of autumn dryness, as outlined in his Differentiating Lurking Pathogens and Externally-Contracted Diseases during Three Seasons: In the depth of autumn at the onset of cool [weather, one observes] each year a pattern characterized by fever and coughing that resembles the wind-warmth pattern of spring. They differ, however, [in that] warmth designates a lesser degree of heat, and coolness a lesser degree of cold. Disorders occurring during the spring are still a remnant of [excessive] closure [of the pores] by winter cold [constraining yang qi in the interior]. Contraction of damage during the autumn occurs during the period that follows the discharge of summer. The character of [these disorders] thus differs in the sense [that the former constitutes an] excess [and the latter a] deficiency. Yet warm pathogens are naturally contracted in the upper [burner], while dryness naturally [also] damages the upper [burner]. Their [inherent] principles thus resemble each other because [in both cases it is] the Lung qi that contracts the disorder [first] . .. Vulgar physicians who know about heat disorders [in the Lungs] use Drain the White Powder (xie bai san) with additions like Scutellariae Radix (huang qin) or Coptidis Rhizoma (huang lian) [to treat it], unaware that they prolong the suffering by increasing the dryness [by such use of bitter herbs], leading to further complications. [Rather], one should use acrid, cooling, and sweet moistening formulas. The dry qi will then naturally be balanced and cured. One must carefully avoid using bitter and drying [formulas] that cut off and scorch the Stomach juices.

Fang Feng Tong Sheng San (Ledebouriella Powder that Sagely Unblocks, p. 290)

The indications for this formula today are not limited to those discussed above, but may also include some types of carbuncles, skin rashes, manic behavior, Intestinal wind, and heat rash. Many modern practitioners use the formula to treat obesity with exterior-interior heat. Modern Japanese physicians also prescribe it for constitutional treatment of metabolic disorders in patients with a strong constitution, excess heat, and constipation. Some recommend that it be taken by these patients twice a year for one to two months in the spring and autumn as a kind of cleanser in order to prevent the accumulation of heat excess.

Ji jiao li huang wan

The main characteristic of this formula is its strategy of eliminating different portions of pathogenic fluids via the urine and bowels, as explained by Cheng Lin in True Explanation of the Essentials of the Golden Cabinet: This is water qi in the Small Intestine. Stephaniae tetrandrae Radix (han fangjl) and Zanthoxyli Semen (jiao mu) guide out fluids at the front because [their] clear [portion] must be cleared via the urine. Rhei Radix et Rhizoma (da huang) and Lepidii/Descurainiae Semen (ting li zi) push out fluids at the rear, because [their] turbid [portion] must be purged via the bowels. By separating [the clear from the turbid] and eliminating them at the front and the back, distention and fullness are diminished and water fluids move [normally once more]. The Spleen qi revolves and body fluids are generated. This method of separation is a very important treatment principle in Chinese medicine that comports with the division of body fluids into clearer and more turbid portions, and with the different methods used in Chinese medicine to drain dampness via the urine and guide out phlegm via the bowels.

Ma Zi Ren Wan (Hemp Seed Pill, p. 81) CA, NCCAOM

The manner in which this formula modifies Minor Order the Qi Decoction (xiao cheng qi tang), and the preference for prescribing it in pill form, make it a relatively mild laxative. Nevertheless, it is inappropriate for all types of chronic constipation. As the early 20th-century physician Yun TieQiao stated in Notated Discussion of Cold Damage Edited for Meaning: "Compared to the Order the Qi Decoctions (cheng qi tang), Hemp Seed Pill (ma zi ren wan) is relatively mild. However, one [still] must use it [only to treat] yang patterns. If one mistakenly employs it for yin patterns, its mildness turns into violence:' Drawing on these discussions as well as his own clinical experience, Chen Zhao-Zu, the modern physician and writer of formula textbooks, suggests three main uses of this formula in contemporary practice: 1. Constipation in the elderly, debilitated, or postpartum or other contexts involving loss of blood or essence, characterized by signs of excess in the yang brightness, but where strong purgation is contraindicated 2. Patients suffering from hemorrhoids who require laxative treatment that does not aggravate the condition 3. Patients who do not exercise but who are neither excessively deficient nor have pronounced signs of damp-heat in the Intestines. Another important indication in contemporary practice is postoperative constipation due to heat and dryness. The early 20th-century physician Cao Ying-Fu used this formula for constipation that is accompanied by sweating or a moist skin. In these cases, such sweating constitutes the equivalent of relatively excessive urination rather than the heat-type sweating associated with yang brightness organ warp patterns. However, the inclusion of moistening herbs such as Cannabis Semen (huo ma ren), Armeniacae Semen (xing ren), and Paeoniae Radix (shao yao) in this formula indicates that, irrespective of the presence of sweat, the skin itself may also be dry.

Ma Huang Tang (Ephedra Decoction, p. 7) CA, NCCAOM

The modern physician Niu Yuan-Qi provides important pointers for how key signs and symptoms that define the classical cold damage pattern (absence of sweating, chills, and high fever) may manifest in contemporary practice. In his experience, the self-prescription of biomedical antipyretics like aspirin, which from a Chinese medical perspective are acrid and cold, often produce some sweating. If this sweating does not resolve the fever, or if the fever actually increases, this indicates the presence of a wind-cold pathogen. Similarly, a predominance of chills need not be present in every single case for which this formula may be indicated. One can make a diagnosis of cold damage if the chills are particularly pronounced at the onset of the disorder or if they persist for a relatively long period of time even as the fever rises. Finally, while many textbooks present fever accompanied by thirst and a rapid pulse to be a distinguishing feature of warm pathogen disorders, Niu notes that they can also occur with wind-cold invasion. In these cases, however, a sensation of dryness in the mouth will not be accompanied by much thirst, or the thirst will be for warm rather than cold drinks. The pulse, although rapid when measured against a normal resting pulse, will be less fast than one would expect given the oftentimes high fever. Besides wind-cold fevers without sweating, the most common contemporary applications of this formula are for cough and wheezing due to cold, and painful obstruction due to wind-cold-dampness. It is also used for nosebleeds with an absence of sweating and a floating, tight pulse. This is a specific type of nosebleed due to cold. In this case, windcold 'bottles up' the exterior and constrains the yang, which surges upward and causes the nosebleed. Less well-known is its usage in gynecology. Both the Chinese and Japanese case history literature documents the successful treatment of painful periods and difficult labor with this formula. This can be explained by the formula's ability to unblock obstruction due to cold, and by the fact that in the classical texts, the word Bladder (pang guang) is a term that can refer to the pelvic organs in general, and not just the bladder. Contemporary writers, like Huang Huang in One Hundred Classic Formulas, thus recommend this formula with the addition of herbs such as Poria (fu ling), Moutan Cortex (mu dan pi), Persicae Semen (tao ren), Artemisiae argyi Folium (ai ye), Paeoniae Radix (shao yao), and Chuanxiong Rhizoma (chuan xiong) for the treatment of dysmenorrhea, abdominal masses, pelvic inflammatory disease, and similar disorders, provided that the overall symptom pattern matches the formula's presentation. This formula is the foundation for a number of other formulas that are used in treating disorders associated with wind affecting the Lungs, including Minor Bluegreen Dragon Decoction (xiao qing long tang), discussed later in this section, and Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction (ma xing shi gan tang), discussed in Chapter 4

Si Ni Tang (Frigid Extremities Decoction, p. 274) CA, NCCAOM

The onset of these symptoms can be very acute and use of the formula is documented for conditions like shock, myocardial infarction, and severe blood loss. As often, however, the formula is used for less severe disorders. The late 19th-century physician Zheng Shou-Quan, for instance, observed that cases of exhausted yang are relatively rare, and that treatment in such cases is often unsuccessful in any event. Although he considered this formula to be effective, he recommended that it be used when the yang was merely deficient and not yet exhausted. This formula may also be used in treating conditions with true cold and false heat. This is a fairly frequent occurrence in clinical practice when exuberant yin in the interior forces yang to float to the surface. Besides classical symptoms like flushing, a dry throat, or a yellow tongue coating, one may also observe severely high blood pressure or a raised heart beat. Modern clinicians also use it for disorders such as chronic inflammatory conditions with a yang-deficient presentation. When the false heat signs include a flushed face and irritability, the decoction should be taken cool.

Gan Lu Xiao Du Dan (Sweet Dew Special Pill to Eliminate Toxin, p. 702)

The original indication of this formula is a damp-warmth epidemic disorder. Unlike seasonal disorders (shi bing), which are caused by pathogenic qi resonating with the five seasons (i.e., wind, heat, fire, dampness, dryness, and cold), such epidemic disorders are specifically defined as being 'unseasonal' (fei shi). That is, they do not occur as the result of an excess in one of the six pathogenic qi, but are caused by transmission of pestilential qi (li qi). As described in Wu You-Ke's Discussion of Warm Epidemics, "Epidemics are contractions of pestilential qi [present] in the world [that one picks up] according to the luck of the year, the fortitude of chance, or the ups and downs of the seasons. It is in the nature of such [pestilential] qi that it strikes irrespective of age or physical fitness." In modern Chinese texts they are regarded as endemic infectious disorders (xiang tu liu xing ji bing). It follows that 'damp-warmth' in this context refers primarily not to the cause, but to the manifestations, which are heat and dampness at the qi level, with heat predominating.

Du Huo Ji Shen Tang (Angelica Pubescens and Sangjisheng Decoction, p. 758) CA, NCCAOM

The pathological mechanism of painful obstruction was first described in Chapter 43 of Basic Questions: "Painful obstruction in the bones causes heaviness; in the blood vessels, [it] causes coagulation and loss of flow; in the sinews, [it] causes contractions with an inability to extend the joints; and in the muscles, [it] causes numbness." Chapter 34 of the same text states: "Deficiency of the nutritive qi causes numbness. Deficiency of the protective qi causes loss of function. Deficiency of both the nutritive and protective qi causes numbness and loss of function:' Consequently, this formula focuses on augmenting the qi and nourishing the blood. It thereby illustrates the principle that proper treatment of a chronic disease requires both tonification of the normal qi and dispelling of the pathogenic influences.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

The primary mechanism common to all of the conditions for which this formula is indicated is the severe accumulation of water in the greater yang warp and the inability of the qi to transform fluids, manifested as urinary difficulty or edema. Another way to put this is that the balance between fluids (water, yin) and qi (fire, yang) has been shifted toward the former. This can occur as a result of invasion of pathogenic wind-cold into the exterior where it fetters the yang qi. It may also reflect a more chronic disorder of qi transformation caused by the interaction of a person's constitution, lifestyle, emotional state, and environmental factors. From an organ perspective, such problems are centered on the Bladder because it is the Bladder from which 'qi transformation issues.' Qi transformation here refers to the process by which the fire at the gate of vitality permeates the body fluids, steaming the clear portion upward and outward to moisten the entire body, while expelling the turbid portion from the body through the urine. If yang and yin no longer interact, water accumulates below and fails to order the yang, which turns into rebellious qi. Because water excess is the root of this pattern, the most effective strategy for restoring a physiological balance between yin and yang is to drain excess fluids (water) through the urine. Yet, at the same time, fire must be tonified in order to guide the yang once more toward the transformation of yin and thereby control the rebelliousness.

Huo Xiang Zheng Qi San (Agastache Powder to Rectify the Qi, p. 691) CA, NCCAOM

The spectrum of indications for this formula listed in the source text is very broad, encompassing not only headache and diarrhea from cold damage, but also sudden turmoil disorders, mountain forest miasmatic malarial disorders, pre and postpartum abdominal pain, and childhood nutritional impairment. This formula treats various types of diarrhea caused by the obstruction of the qi dynamic in the middle burner. The most important of these is 'urgent diarrhea' (sun xie), the nature of which is explained in Wondrous Lantern for Peering into the Origin and Development of Miscellaneous Diseases: An overabundance of dampness causes urgent diarrhea. [In fact,] it is only due to dampness. Some wonder if wind, cold, heat, and deficiency cannot also lead to this disorder. If the Spleen is strong and without dampness, these four [pathologies] cannot interfere [with its function]. How could there then be diarrhea?

Da Cheng Qi Tang (Major Order the Qi Decoction, p. 63) CA, NCCAOM

The principal pattern for which this formula is indicated includes focal distention, abdominal fullness, dry stools, and symptoms of yang brightness-type interior excess heat. Although the formula is mentioned nineteen times in Discussion of Cold Damage for a variety of conditions, it is most frequently discussed in connection with this pattern. In addition to the other patterns listed under INDICATIONS, the formula has also been used for lesser yin-warp disorders that present with similar signs and symptoms. In Essentials from the Golden Cabinet, it is recommended for internal blood stasis accompanied by spasms as well as some types of diarrhea and other disorders. Although the indications vary considerably, each of these presentations shares the same underlying mechanism: heat excess accumulating in the Stomach and Intestines where it injures the fluids and forms clumps that obstruct the downward flow of qi. It can thus be used, for instance, to regulate menstruation in women with heat excess. Once this is eliminated, the flow of qi becomes regular, and once the flow of qi is regular, its control over the flow of blood and menstruation will normalize. This formula is also used to treat such problems as visual disturbances, dizziness, and wheezing with inability to lie down when the pathological dynamic is the same. Following the same rationale, this formula is used to treat closed-type wind-stroke.

Lian Po Yin (Coptis and Magnolia Bark Decoction, p. 705)

The relatively large dosage of Phragmitis Rhizoma (lu gen) has led some commentators to suggest that this substance should be regarded as the chief herb. In view of the formula's name and its focus on the regulation of the qi dynamic, this view appears to be off the mark. By clearing heat and facilitating the resolution of dampness from the Lungs and Stomach while simultaneously generating fluids, Phragmitis Rhizoma (lu gen) secures the fluid metabolism. In a condition marked by severe loss of body fluids through vomiting and diarrhea, this is a key strategic objective. This justifies its large dosage without implying that it serves as chief herb in the formula.

Li Zhong Wan (Regulate the Middle Pill, p. 257) CA, NCCAOM

The reliance of the digestive functions of the middle burner on the yang qi supplied by the gate of vitality makes it particularly vulnerable to damage from cold. The reliance of other organ systems on postnatal essences, in turn, implies that impairment of the transportive and transformative functions of the middle burner will be felt throughout the body. In Clear Explanations to the Discussion of Cold Damage and Later Systematic Differentiations, the early Qing-dynasty physician Cheng Ying-Mao explains this pathology: The movement of yang begins with warmth. [When the Spleen) receives the warm qi, it transports the food essences. The food qi ascends and the qi of the middle [burner) is supported. Hence, the name [of this formula refers to) regulating the middle. In fact, its power to regulate the middle is bestowed by the yang of the middle burner. If Stomach yang is deficient, the qi of the middle burner is plundered, the chest center [no longer carries out its] disseminating functions, and the six yang organs lose their powers of sprinkling and ripening. It is like removing firewood from under the cauldron. Clear food diarrhea below, loss of taste above, deprivation of the five yin organs, and all other manifestations result from this. Cheng Ying-Mao's analysis deserves some attention because, unlike contemporary textbooks, it focuses on the functions of the middle burner yang (indicated by reference to the Stomach as a yang organ) rather than on the Spleen. The original use of this formula in Discussion of Cold Damage, where it is listed as treating greater yin disorders, corroborates this view. Greater yin disorders imply a deficiency in the functions of the middle burner yang, as opposed to the yang excess disorders grouped under the yang brightness category. In Chinese medicine, this is summed up in the saying, "Excess means the yang brightness, deficiency the greater yin:' In Formulas in Verse from the Scholar's Studio in Two Volumes, the modern scholar-physician Cheng Men-Xue explains this relationship: The greater yin and yang brightness, a yin and a yang organ, Spleen and Stomach as fellow officials, these two are integrated with each other ... [The fact that] patterns listed under the heading of greater yin disorders [include] vomiting and inability to get food down [indicate that these] are not simply Spleen but also Stomach disorders. One should [therefore] differentiate according to the maxim, 'Because heat [patterns] are yang, they are subordinated to the yang brightness and the Stomach yang organ. Because cold [patterns] are yin, they are subordinated to the greater yin and the Spleen yin organ. However, if the Spleen is cold, the Stomach is also cold. Therefore, greater yin [disorders] include vomiting and the inability to get food down. When the Stomach is hot, the Spleen is also hot. Therefore, yang brightness [disorders] include the Spleen bind pattern.' [In all these cases, one does not view the Spleen and Stomach separately, but] merely differentiates according to what is primary or secondary. Cheng also provides a useful differentiation of the similarities and differences of greater yin and yang brightness disorders: [When] the greater yin stores cold, there is clear, thin diarrhea below, not all of the food is transformed, and the urine is clear and increased. This is very different from foul-smelling heat type diarrhea with a yellow or red color and the consistency of soup, tenesmus, and the hot, dark, and reduced urination [associated with yang brightness disorders]. In greater yin disorders, the abdomen is soft on palpation, whereas in yang brightness disorders, it is hard. Abdominal distention in yang brightness disorders is unrelieved, whereas in greater yin disorders there are periods of aggravation and amelioration. Although there are commonalities, there are also clear differences [allowing us] to differentiate excess and deficiency.

Chuan Xiong Cha Tiao San (Ligusticum Chuanxiong Powder to be Taken with Green Tea, p. 628) NCCAOM

The root cause here is cold that was not dispersed and has transformed into heat. In contrast to the principal formula, this variation focuses on obstruction of the Lung channel due to chronic wind-cold that has transformed into heat. Grind into a fine powder. Take 6g after meals three times daily together with aged, good-quality green tea.

Si Ni Tang (Frigid Extremities Decoction, p. 274) CA, NCCAOM

The significance of this formula lies in its ability to strengthen the yang of both the gate of vitality and the middle burner. Furthermore, it is formulated in such a way as to warm and strengthen the yang without injuring the yin. This is important here because the formula's indications include vomiting or diarrhea, both of which can injure the yin. The moderating and qi-augmenting qualities of Glycyrrhizae Radix (gan cao) make an important contribution to the efficacy of this formula. In fact, it is listed first in the source text, and its dosage is as large or larger than that of the other ingredients. Both Cheng Wu-Ji, the famous Song-dynasty commentator on the Discussion of Cold Damage, and the editors of the Golden Mirror of the Medical Tradition therefore considered Glycyrrhizae Radix (gan cao) to be the chief herb. The modern Shanghai physician Cheng Men-Xue admonished his students "not to think lightly" of it because it lacked the apparent power of the heating herbs. The importance of this formula is demonstrated by the fact that it is mentioned twelve times in Discussion of Cold Damage. The scope of its use is succinctly summed up by the Qing-dynasty physician Wang Zi-Jie in Selected Annotations to Ancient Formulas from the Garden of Crimson Snow: [This formula] can be used in patterns of all three yin warps as well as one [i.e., the greater] yang warp [provided they] are characterized by inversion [as the key symptom]. One employs it in lesser yin [disorders] in order to rescue the yang of the primal sea [i.e., the Kidneys]. In greater yin [disorders], one uses it to warm cold within the yin organ [i.e., the Spleen]. Terminal yin [disorders characterized by ]lack of warmth and inversion where devastation of yang is threatening cannot be helped without this [formula]. Finally, one also uses it in greater yang [disorders] where inappropriate sweating has devastated the yang.

Qing Wei San (Clear the Stomach Powder, p. 191) CA, NCCAOM

The source text notes that the cause of this disorder is the improper use of hot, tonic herbs. At present, the accumulation of heat in the Stomach is usually attributed to overconsumption of rich or fried foods, or (paradoxically) of cold foods, which constrains the yang qi and causes its transformation into fire. This is a very effective formula in the treatment of toothache, swollen gums, and bleeding of the gums due to Stomach fire; it can be modified for treating many types of oral problems. While all commentators agree on these indications, they differ in their perspectives on the chief herb and, by implication, the precise disease dynamic that this formula treats. Modern textbooks generally follow the Qing-dynasty scholar Wang Ang in defining Coptidis Rhizoma (huang lian) to be the chief herb. They give two apparently compelling reasons. First, Coptidis Rhizoma (huang lian) is the herb with the closest affinity to the Stomach, which is the root of the disorder. Second, the source text itself emphasizes the role of Coptidis Rhizoma (huang lian) as the chief herb by providing detailed instructions regarding adjustment of its dosage. Other physicians have expressed divergent views. The late-Qing dynasty physician Tang Zong-Hai, for instance, emphasized the importance of Cimicifugae Rhizoma (sheng ma) as representing the dispersing method by which the formula eliminates heat in accordance with the principle that fire from constraint should be discharged. His contemporary, Luo Mei, pointed to the absence in the list of indications of signs or symptoms that are usually associated with yang brightness channel disorders. For this reason, he considered the root of the disorder to be heat in the blood and accordingly designated Radix Rehmanniae Glutinosae (sheng di huang) as the chief herb. Read together, these different perspectives lead to a deeper understanding of the disease process treated by this formula. As Ye Tian-Shi noted, "The gums are the collaterals of the Stomach:' The collaterals pertain to blood, while signs and symptoms of the disorder imply the presence of fire toxin. Such toxin readily enters the blood in the Stomach via food, drink, or, as the source text notes, the improper use of medication. If blood is deficient, it will readily generate wind, which in turn leads fire toxin upward into the collaterals where it manifests as toothache and a progressive ulceration of the gums. To address all aspects of this pathoglogy, the formula combines herbs that drain damp-heat from the Stomach, nourish and cool the blood, and disperse constraint and relieve toxic heat within the collaterals.

Dao Chi San (Guide out the Red Powder, p. 195) CA, NCCAOM

The source text prescribes this formula for children with a pattern of heat in the Heart. According to its author, the famous Song-dynasty pediatrician Qian Yi, this pattern can be diagnosed "by examining [how a child] sleeps. There is warm breath in the [open] mouth and they may sleep face down with bouts of teeth grinding. All of these indicate Heart heat." There has been considerable debate over whether this pattern denotes heat from excess or deficiency. The proponents of heat from excess argue that the presence of Akebiae Caulis (mu tong) and Lophatheri Herba (dan zhu ye), which leach out fluids, can also injure the yin. They would not have been included had the formula been intended for treating heat from deficiency. On the other side, the proponents of heat from deficiency argue that the absence of Coptidis Rhizoma (huang lian), which treats heat excess in the Heart channel, would certainly have been included had the formula been intended for treating heat from excess. A close look at the source text reveals that both of these views are incomplete. Craft of Medicinal Treatment for Childhood Disease Patterns contains a description of'Heart qi excess' (xin qi shi) that lists a desire to sleep face up (xi yang wo) as one of its signs. This pattern is treated with Drain the Epigastrium Decoction (xie xin tang), a formula containing Coptidis Rhizoma (huang lian) as its chief herb. Clearly, therefore, the pattern of Heart fire is not simply one of Heart excess. In another passage, Qian Yi notes that "Dark red [eyes imply] Heart heat. This is governed by Guide Out the Red Powder (dao chi san). Pale red eyes [imply] Heart deficiency heat (xin xu re). This is governed by Rehmannia and Rhinoceros Powder (sheng xi san)." The latter formula contains Radix Rehmanniae Glutinosae (sheng di huang) but not Akebiae Caulis (mu tong). Clearly, therefore, Heart heat is not synonymous with heat from deficiency. It follows that Qian Yi's disease category'Heart heat' refers to a unique pattern that corresponds to an instability that Golden Mirror of the Medical Tradition defines as "water deficiency with fire that is not excessive" (shui xu huo bu shi). This description attempts to capture a pathology that reflects the immature development of the qi dynamic in children. Because the yin and yang are still unstable and ungrounded, the qi in children readily moves this way and then that, becoming hot or cold, excessive or deficient, without either aberration from the norm indicating a substantial underlying excess or deficiency. The present formula responds by guiding out fire excess without damaging the yin, and by generating yin fluids without retaining the pathogenic heat.

Xie Bai San (Drain the White Powder)

The source text refers to the disorder treated by this formula as 'Lung overabundance in children' (xiao er fei sheng). Not until the Ming and Qing eras did physicians define the nature of this overabundance as 'Lung fire' and provide a detailed analysis of the disease dynamic and etiology. With an overabundance of heat, the clearing and clarifying function of the Lungs is impaired and the qi rebels upward, producing a high, clear-sounding cough with little sputum. The heat itself is thought to arise from the oscillation between excess and deficiency that reflects the immaturely developed yin and yang in children. This pattern must therefore be distinguished from both external excess, where pathogenic heat constrains the diffusion of Lung qi, and internal deficiency, where an objective lack of fluids and essences is insufficient to moisten and cool the Lungs. For this reason, the formula focuses on draining heat without employing excessively cooling or bitter substances such as Gypsum fibrosum (shi gao) or Scutellariae Radix (huang qin) that would damage the qi dynamic; and it tonifies the qi and yin indirectly by strengthening earth and clearing deficiency heat rather than relying on sweet, moistening herbs such as Ophiopogonis Radix (mai men dong) or Asparagi Radix (tian men dong) that would increase stagnation. The famous Qing-dynasty physician Fei Bo-Xiong concisely summed up this strategy: "Clearing Lung fire and supplementing the Spleen and Stomach-this is the method of caring for the mother [in order to treat the child]. If one were to add [bitter, cold herbs that damage the earth like] Coptidis Rhizoma (huang lian), one would let go of the guiding [principles]laid down within the formula's composition:'

Zeng Ye Tang (Increase the Fluid Decoction, p. 677)

The treatment strategy embodied in this formula is modeled after Wu You-Ke's Order the Qi and Nourish the Nutritive Decoction (cheng qi yang rong tang), discussed in Chapter 2, which Wu Ju-Tong admired for its combination of tonifying and downward-draining herbs. Over the years, the use of this formula has been expanded to include any constipation due to yin deficiency, regardless of etiology. Based on the functions of its individual ingredients, the formula is also commonly used for nutritive-level heat with signs of dryness in the middle burner. Used together, more often in various synergistic pairs, and sometimes alone, its three ingredients are found in formulas that treat warm-pathogen disorders or fire toxin at almost any level. They can, for instance, be added to Honeysuckle and Forsythia Powder (yin qiao san) for patients with internal heat due to yin deficiency, even at the onset of such disorders. In addition, they are invariably included in formulas that treat latestage feverish disorders, including those of the cold-damage type, such as Prepared Licorice Decoction (zhi gan cao tang), which contains Ophiopogonis Radix (mai men dong) and Rehmanniae Radix (sheng di huang). This attests to the core objective of preserving the fluids and maintaining fluid metabolism in the treatment of all such disorders. First outlined in the treatment strategies of Zhang Zhong-Jing, it is from this observation that the composition of the present formula was derived.

Dang Gui Si Ni Tang (Tangkuei For Frigid Extremities, p. 252)

The use of this formula has been expanded over the centuries to encompass a variety of conditions due to cold invading the channels with underlying blood deficiency. Common manifestations include headache (including migraines), pain in the joints, irregular menstruation, abdominal pain and cold, pain in the lower back and legs, and chest pain. In all the cases, the symptoms tend to be precipitated or aggravated by exposure to cold, including cold food or drink. Moreover, based on Japanese precedents, the modern physician Huang Huang in One-Hundred Classic Formulas extended its use to patterns where the key symptoms of cold extremities and faint pulse are accompanied by signs of disordered body fluids. This might include increased sweating, particularly of the feet, vaginal discharge, increased salivation, or changes in urination. The thinking behind this usage is that cold also inhibits the normal dissemination of body fluids. In this formula, the issue is addressed by including the herbs Akebiae Caulis (mu tong) and Asari Herba (xi xin), which, besides unblocking the vessels and dispersing cold, also facilitate water metabolism and promote urination.

Bai Tou Weng Tang (Pulsatilla Decoction, p. 210) CA, NCCAOM

The use of this formula has been expanded to the treatment of other conditions due to heat toxin or damp-heat in the lower burner such as painful or bloody urinary dysfunction. Many of the materia medica books of the Ming and Qing periods note that the assistant herb, Fraxini Cortex (qin pi), is beneficial to the eyes. For example, in Hidden Aspects of the Materia Medica, the 16th-century writer Chen Jia-Mo noted that it is a specific herb for ophthalmology. For this reason, some modern practitioners use the formula in treating acute eye disorders due to damp-heat.

Xiao Yao Wan (Rambling Powder, p. 120) CA, NCCAOM

The very wide range of potential applications of this formula was already noted in the source text, which recommends it for such disorders as blood deficiency with fatigue, heat in the five centers, painful extremities and trunk, dizziness and heaviness of the head, palpitations, red cheeks, dry mouth and throat, fever, night sweats, reduced appetite, increased desire to sleep, contention between the blood and heat with irregular menstruation, periumbilical and abdominal pain, and malarial alternating fever and chills. The same text also recommends it for treating "virgin girls with weak blood and yin deficiency, disharmony of the nutritive and protective qi, phlegmy cough, tidal fever, and wasting of the limbs that slowly progresses to a steaming bone condition:' The many heat symptoms in these original indications suggest that the formula may be most useful for treating patterns characterized by significant constraint of yang qi, that is, the ministerial fire that is often understood to be under the Liver's control. Such constraint is enabled by deficiency of blood, which naturally leads to yang excess. This explains the use of Bupleuri Radix (chai hu) as the chief herb. Furthermore, prior to the Ming dynasty, the herbs Bupleuri Radix (chai hu) and Stellariae Radix (yin chai hu) were generally indistinguishable. Wang Mian-Zhi suggests that, in cases characterized by strong deficiency fire due to blood deficiency, Stellariae Radix (yin chai hu) may be the more appropriate choice.

Si Ni Tang (Frigid Extremities Decoction, p. 274) CA, NCCAOM

There has been much debate among commentators regarding both the type of Aconiti Radix lateralis (fu zi) to be used and its dosage. Traditionally-minded physicians like Cheng MenXue point out that in Discussions of Cold Damage, Zhang Zhong-Jing uses untreated Aconiti Radix lateralis (fu zi) to treat serious and acute disorders but that its toxicity is moderated both by the use of Zingiberis Rhizoma (gan jiang) and Glycyrrhizae Radix (gan cao), as well as by extended boiling. For this reason, Cheng Men-Xue recommends that it also be used untreated in this formula. However, according to Chinese laws governing poisons, the unprepared herb is not available at all except through a very small number of herb preparation factories, and then only by special prescription. This means that at present, the unprepared herb is no longer used, except in some topical preparations. Physicians in contemporary China consider 6-10g to be the standard dosage for Aconiti Radix lateralis preparata (zhi fu zi) in this formula, but may increase it up to l5Og for very acute cases.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

There has been much debate among commentators regarding the identity of the chief ingredient. Given the inclusion of the term ~ ling in the formula's name, the Jin-dynasty scholar Cheng Wu-Ji, the first extant commentator on the Discussion of Cold Damage, believed this to be Poria (fu ling). Cheng explains his reasoning in Discussion Illuminating the Principles of Cold Damage: "[The word] ~ ling implies causation (ling) in the sense of issuing a command (hao ling). Unblocking and moving the body fluids and curtailing Kidney pathogens depends on issuing a special command, which is the effect of [fulling:' In Selected Annotations to Ancient Formulas from the Garden of Crimson Snow, the Qing-dynasty writer Wang Zi Jie supplied a different interpretation of the same term to support his claim that Poria (fu ling) and Polyporus (zhu ling) jointly fulfill the function of chief herb: "Ling~ refers to deputy herbs [because they are subjects of a ruler]. But because Poria (fu ling) and Polyporus (zhu ling) mutually accentuate each other, they can function as chiefs among the five [herbs of which this formula is composed]. Hence, it is called Five Ling [Powder]." The analysis above follows those physicians who accord the position of chief ingredient to Alismatis Rhizoma (ze xie), partly because of its larger dosage, and partly because of its special function. The contemporary physician Ran Xue-Feng outlines this argument in Annotated Fine Formulas from Generations of Famous Physicians: The composer of this formula only used Alismatis Rhizoma (ze xie) in a large dosage. The [functions of] Alismatis Rhizoma (ze xie) do not exhaust themselves in making the water that has form and substance move downward [into the lower burner]. It also is able to make the water qi that does not move [because it is constrained in the lower burner] ascend to enrich [the upper burner]. Therefore, [in Chinese, the herb is] is called 'moistening' (ze) and 'draining' (xie). Although this is clearly so, most people only know that it drains but do not know that it also moistens. Yet this supplies a somewhat more specific understanding of [why one would] use Alismatis Rhizoma (ze xie) in a larger dosage. Yet another group of commentators, among them the Qingdynasty writers Shen Jin-Ao and Shen Shi-Fu, suggest that Cinnamomi Ramulus (gui zhi) has the most important functions in the formula, that is, warming the yang to transform water in the interior and mobilizing the protective qi in the exterior to dispel pathogenic wind-cold. Chen Chao-Zu, a contemporary expert on formulas, broadly agrees with this view, arguing that function rather than dosage is the criterion according to which the importance of any individual herb in a formula should be evaluated. From this perspective, Cinnamomi Ramulus (gui zhi) is the only herb that addresses both the relative deficiency of yang (by warming and dispersing fire) and the relative excess of yin (by promoting the movement and transformation of water) at the heart of all the various patterns treated by this formula. In Treatment Strategies and Formulas in Chinese Medicine, Chen Chao-Zu also advises, however, against placing too much emphasis on assigning herbs into categories rather than on understanding their interactions: A complex formula is often composed of three types of herbs: those that eliminate the cause of the disorder, those that regulate the function of the yin and yang organs, and those that circulate and unblock or tonify and refill the qi, blood, body fluids, and essence. Among different herbs, each has its [specific] uses and its synergies with others. In going back to the source [of the efficacy of a formula,] it is therefore unnecessary to order them according to their relative values.

Bu fei tong

This can be seen as a variation of Generate the Pulse Powder (sheng mai san) for which the main indication is chronic cough due to Lung deficiency. The cough may either be dry or productive. Although this may appear to be contradictory, both manifestations can result from the same underlying disease dynamic. The Lungs are the 'upper source of water.' Through their control of the skin and pores, they regulate the dispersion of body fluids to the exterior. Through their downward direction of qi, they move the fluids into the lower burner and the Kidneys. If the Lung qi is too weak to fulfill these functions, water accumulates in the Lungs, which becomes visible as phlegm. The Kidneys, furthermore, are no longer nourished by the water they receive from the Lungs. As the Kidney yin declines, water is no longer steamed upward to moisten the Lungs, causing dryness. Such dryness further weakens the qi, both because the lack of yin control can lead to the leakage of qi as sweat, and because, without the movement-facilitating moisture afforded by the body fluids, the qi stagnates and over time diminishes. The composition of this formula succeeds in addressing all of these problems. It tonifies the Lung qi with Ginseng Radix (ren shen) and Astragali Radix (huang qi), facilitates moistening, downward-directing, and the draining of excess pathological water through the urine with Mori Cortex (sang bai pi) and Asteris Radix (zi wan), nourishes the Kidney yin with Rehmanniae Radix preparata (shu di huang), and astringes the excessive upward and outward movement of qi and fluids with Schisandrae Fructus (wu wei zi). This makes it an ideal formula for treating chronic cough in older patients or in those weakened by another illness or medical treatment. This formula also is a good example of the use of Rehmanniae Radix preparata (shu di huang) in the treatment of phlegm disorders.

Long Dan Xie Gan Tang (Gentiana Longdancao Decoction to Drain the Liver, p. 201) CA, NCCAOM

This formula can be used in treating a wide variety of complaints. There are three criteria for diagnosing heat in the Liver channel, the condition for which this formula is indicated: (1) a wiry, rapid pulse; (2) a red tongue or red dots along the sides of the tongue; and ( 3) dark urine or urinary difficulty. All commentators agree that because 'the Liver carries ministerial fire within; disruption of the flow of Liver qi in a person with a strong constitution produces Liver fire. There is less agreement, however, as to why such fire should so often manifest in the form of damp-heat. In the modern text Elaboration of Medical Formulas, Fu Yan-Kui and colleagues point to the relevance of the close relationship among the Liver, Gallbladder, and Triple Burner. Blazing heat in the Liver and Gallbladder channels obstructs water metabolism in the Triple Burner such that water is no longer properly excreted, and the accumulation of heat and water combine to form damp-heat. A contrary view is advanced in Convenient Reader of Established Formulas, whose author, Zhang Bing-Chen, thinks that dampness must already be constitutionally present or enter into the body from the outside. Both perspectives are clinically useful, but the fact that Liver function is responsible for both 'dispersing and draining' (shu xie), and the presence of dampness and edema in many Liver pathologies irrespective of constitution or context, strongly favors the first view. The herbs in this formula cool heat without causing stasis, dispel pathogenic qi, and cause it to descend without injuring the normal qi. It is an excellent formula for treating the symptoms and underlying mechanisms associated with Liver and Gallbladder heat excess that can be adjusted to fit the myriad manifestations of this pathology in clinical practice. Indeed, Encyclopedia of Chinese Medical Formulas lists 25 formulas with the same name but slightly different ingredients, a few of which are discussed below.

Lian Po Yin (Coptis and Magnolia Bark Decoction, p. 705)

This formula focuses on clearing and transforming dampheat and regulating the ascending and descending functions of the middle burner. It does not treat the diarrhea directly because this is unnecessary, since once the damp-heat is resolved and the qi is regulated, the diarrhea will stop. The focus on the qi dynamic is evident in the various groups of synergistic herbs that act on the ascending and descending functions to build the momentum of the formula. In this sense, it closely resembles the action of Pinellia Decoction to Drain the Epigastrium (ban xia xie xin tang), analyzed in Chapter 3. Both formulas remove damp-heat obstructing the qi dynamic by draining it through the bowels. However, whereas Pinellia Decoction to Drain the Epigastrium (ban xia xie xin tang) employs sweet and moderate herbs to treat conditions of mixed excess and deficiency, the present formula relies on fragrant and aromatic herbs to treat conditions where heat and dampness are equally pronounced. Like Pinellia Decoction to Drain the Epigastrium (ban xia xie xin tang), however, its action is not limited to acute conditions. It can be used for all kinds of patterns characterized by damp-heat obstructions of the middle burner that manifest with diarrhea, abdominal distention, belching, or vomiting. Such conditions are not limited to digestive disorders, but also include impotence, infertility, and postviral fatigue syndrome.

Ma Xing Shi Gan Tang (Ephedra, Apricot Kernel, Gypsum, and Licorice Decoction, p. 183) NCCAOM

This formula is a variation of Ephedra Decoction ( ma huang tang), with Gypsum fibrosum (shi gao) substituted for Cinnamomi Ramulus (gui zhi). It is a good example of how the substitution of just one ingredient can significantly alter the actions of a formula. In paragraph 63 of Discussion of Cold Damage, this formula is prescribed for greater yang-stage disorders after sweating when Cinnamon Twig Decoction (gui zhi tang) is inappropriate, if there is sweating and wheezing without intense heat. This requires some explanation as the formula can be used for patients with significant fevers. Commentators such as You Yi have explained the last phrase to mean that there is no significant heat in the exterior because it has entered the Lung. Similarly, the contemporary physician Nie Hui-Min in Nie's Study of Cold Damage notes that this also means that the patient does not experience the interior heat of a yang brightness disorder with irritability and thirst. She notes that this is a way to differentiate this presentation from that of wheezing due to yang brightness heat upwardly disturbing the Lungs. Later generations of practitioners have used the formula in the treatment of cough with viscous and difficult-to-expectorate sputum, labored breathing, a red tongue, and a rapid pulse, irrespective of the color of the tongue coating or the presence of fever or sweating. Others, however, such as the modern expert on classical formulas Huang Huang in One-Hundred Classic Formulas, consider sweating (indicating that the Lungs have lost their control over the opening and closing of the pores) to be a key symptom, but argue that this may be either a cold or hot sweat. Based on his analysis of both the presentation and the ingredients of this formula, the modern formula expert Chen Chao-Zu emphasizes that it is properly used when the fluids are somewhat stopped up and form thin mucus, but that it should not be used if the fluids are actually damaged. This formula is used for a wide variety of Lung disorders. For example, it may be used in treating children with frequent and poorly controlled urination (the main complaint) accompanied by coughing and wheezing. This is an example of focusing treatment on the upper burner for disorders of the lower burner. It can also be used in treating allergic asthma or allergic rhinitis, both of which are conditions without fever and thus strong heat.

Xing Shu San (Apricot Kernel and Perilla Leaf Powder, p. 663) CA, NCCAOM

This formula is a variation of Perillia Leaf and Apricot Kernel Drink (xing su yin), an earlier formula from Golden Mirror of the Medical Tradition. That formula was used to treat wind-cold residing in the Lungs, where it caused wheezing. It is composed of Perillae Folium (zi su ye), Aurantii Fructus (zhi ke), Platycodi Radix (jie geng), Puerariae Radix (ge gen), Peucedani Radix (qian hu), Citri reticulatae Pericarpium (chen pi), Glycyrrhizae Radix (gan cao), Pinelliae Rhizoma preparatum (zhi ban xia), Armeniacae Semen (xing ren), and Poria (fu ling). This formula, in turn, is a variation of Ginseng and Perilla Leaf Drink (shen sil yin), discussed in Chapter 1, a Song-dynasty formula used for treating wind-cold disorders with qi deficiency. By the early 18th century, the older formulas appear to have fallen out of favor, for Wu Ju-Tong remarked: "This formula dominates the contemporary treatment of wind-damage cough during [all of the] four seasons." This suggests that Wu Ju-Tong, whose Systematic Differentiation of Warm Pathogen Diseases is generally regarded as the source text for this formula, was not himself its author, but merely expanded its scope of application. Wu Ju-Tong also explained how and why cold-dryness produces stagnation: Dry qi rises following the autumnal equinox and [comes to an end] before the slight snow [i.e., the 20th solar term and beginning of winter). It is commanded by the cool qi of yang brightness dryness metal. The Classic states, 'The nature of yang brightness is clear discharging from the middle [burner, causing] pain in the right flank and sloppy diarrhea [if it is obstructed]. Internally, it manifests as throat obstruction. Externally, it causes prominent bulging (tui shan). When the great coolness clarifies and kills, the flowers change their appearance, the hairy pests die out, there is discomfort in the chest, the throat is blocked, and one coughs.' According to this classical text, dryness will cause cool qi to be contracted by the people. As Liver wood receives this pathogen, it transforms into dryness . ... Dry disorders therefore come under [the wider rubric] of cold. They are referred to as lesser cold because these disorders and the contraction of cold are of the same kind. Wu Ju-Tong thus defines cool-dryness to be a secondary consequence of mild cold. Cold slows down the qi dynamic. This leads to qi stagnation, on the one hand, and the failure of qi transformation with production of pathological fluids on the other. Both prevent physiological fluids from performing their moistening function. This explains why acrid, warming herbs used to unblock the qi dynamic and resolve the exterior can also treat dryness.

Huo Xiang Zheng Qi San (Agastache Powder to Rectify the Qi, p. 691) CA, NCCAOM

This formula is also used for mild cases of mountain mist miasmic malarial disorder (shan Zan zhang nue). This is thought to be contracted from the mists of the mountains and forests, considered to be damp and hot in nature. Manifestations include intermittent fever and chills, disorientation, and madness with delirious speech or loss of voice. Miasmic disorders were viewed as one type of abnormal seasonal qi, regarded as one of the main causes of epidemic disorders in traditional China. The early 19th-century physician Chen Nian-Zu explained the treatment strategy appropriate for such disorders: The q i of [any one of] the four seasons that does not arrive at its proper time enters through the mouth and nose; it is different from the pathogenic qi that injures the channels [and enters through the skin]. Therefore, do not use strong sweating [herbs] to release the exterior, but aromatic substances that promote the proper flow of qi. In late imperial China, the occurrence of miasmic gi was particularly linked with the southeastern provinces of the country, known collectively as Lingnan, whose warm and moist climate was considered unsuitable for the northern Chinese then settling there. It is undoubtedly due to this association that this formula is still one of the most important formulas for treating digestive disorders contracted while traveling, that is, when one encounters gi to which one is not accustomed. Pogostemonis/ Agastaches Herba (huo xiang), the chief in this formula, is one of the main herbs in the materia medica for treating miasmic disorders. Encountering the Sources of the Classic of Materia Medica notes: "In all cases of unseasonal epidemic disorders or miasmic malarial disorders, one uses [this herb] to awaken the Spleen and strengthen the Stomach. Then the pathogenic gi naturally has no place where it might lodge, and [the condition) is cured." Explanation of the Classic of Materia Medica attributes this capacity not only to its well-known aromatic, dampness-transforming nature, but also postulates a more specific toxicity-resolving effect: Pogostemonis/ Agastaches Herba (huo xiang) has a qi that is slightly warming. Its constitution is that of the wood qi of early spring .... Its flavor is acrid, sweet, and without toxicity. Possessing the two flavors of metal and earth, it enters into the hand greater yin Lung channel and the foot greater yin Spleen channel. Its qi and flavor are both ascending .... If a damp toxin enters the Spleen, sweetness can resolve such toxicity. Noxious qi is the noxious qi of pathogens. The Lungs govern the qi. Acrid [flavor] can disperse pathogens, hence [it also] governs [the dispersion of noxious qi ].

Zhu Ling Tang (Polyporus Decoction, p. 731) CA, NCCAOM

This formula is also used to treat hot or bloody painful urinary dribbling with lower abdominal fullness and pain. Recently, its use has been further extended to the treatment of diarrhea in infants caused by damp-heat and injury to the yin characterized by reduced urination, dry skin, sunken eyes, and fever that worsens at night.

San Ren Tang (Three Seed Decoction, p. 699)

This formula is an example of the innovative treatment of damp-warmth disorders developed during the Qing dynasty. First listed in Wu Ju-Tong's Systematic Differentiation of Warm Pathogen Diseases, its composition was inspired by the case records of the influential physician Ye Tian-Shi. Hua Xiu-Yun, one of the editors of Case Records as a Guide to Clinical Practice, has analyzed Ye's approach to the treatment of early-stage damp-warmth disorders: The human body is like a microcosm. If we inspect master [Ye Tian-Shi's] treatment strategies, we [note that he treated patterns] of dampness obstructing the upper burner by using [herbs] that open the Lung qi, assisted by bland [herbs] that leach out [dampness] and promote [the qi transformation] of the Bladder. This is the same principle as opening the upper sluice gate and unlocking the branch canals in order to direct water by utilizing its [inherent] momentum to flow downward. This strategy was conceived in response to a perceived failure of existing methods to adequately diagnose and treat earlystage damp-warmth disorders. This is expressed most clearly by Wu Ju-Tong himself: Hereditary physicians do not understand [that the symptoms with which these disorders present are those of] dampwarmth. They note [that the patient suffers from] headache, chills, a heavy body and pain, think that it [indicates] cold damage, and [employ formulas to induce] sweating. [This] sweating injures the Heart yang. Dampness [furthermore] follows the acrid, warming, exterior-releasing herbs, steaming and fuming. to rebel upward. Veiling the Heart orifices internally, [such treatment] causes impaired consciousness. Veiling the clear orifices above, it causes deafness, heavy eyes, and inability to talk. [Such physicians] notice fullness of the middle burner and lack of appetite. Thinking that this is [clumping] congealing, and stagnating [of the qi dynamic], they vehemently purge it. Mistaken purgation, [however,] damages the yin and severely curbs the ascending of the Spleen yang so that the Spleen qi inversely sinks [downward]. The damp pathogen avails itself of this momentum to flood the interior, causing cavernous diarrhea. [Such physicians] note the afternoon fever. Thinking that it [indicates] yin deficiency, they employ soft herbs to moisten. [But] dampness is [already] a sticky, stagnating yin pathogen [to which they now] add even more soft, moistening yin herbs. The two yin combine, their similar qi assisting each other. Like pouring molten metal into cracks, it creates a momentum that can [no longer] be resolved .... Damp qi spreads throughout [the body]. Its original nature is shapeless. If one uses large doses of herbs with a turbid, enriching taste, treatment turns into disaster. In my district, lurking summerheat-damp-warmth is commonly called 'autumnal obtuseness' (qiu dai zi) and is treated with strategies from Mr. Tao's Six Texts on Cold Damage. I do not know from where this learning comes. When obtuse physicians instead call a condition obtuse, is that not slander?

Xin Jia Xiang Ru Yin

This formula is another example of how physicians associated with the warm pathogen current in Chinese medicine adjusted established formulas to serve a new understanding of pathology. One of the most important innovations of the warm pathogen disorder current is the importance accorded to the Lung greater yin at the onset of externally-contracted disorders. Previously, damp-heat disorders, including summerheat, had been approached primarily through a focus on the functions of the Spleen and Stomach. Physicians such as Ye Tian-Shi, Xue Sheng-Bai, and Wu Ju-Tong argued that as long as pathogens had not yet entered the middle burner (absence of digestive symptoms), treating the middle burner could actually prolong the course of the illness by causing a pathogen to fall inward. These physicians developed a style of treatment that relied on acrid and light herbs to thrust out pathogens that were obstructing the Lung greater yin. As Wu Ju-Tong noted in Systematic Differentiation of Warm Pathogen Diseases, "The position of the Lungs is the highest [in the body]. Herbs that are too heavy go past the place where the disorder is [ actually ]located:' The presentation for which Newly Augmented Mosla Drink (xin jia xiang ru yin) is indicated mimics that of a cold damage disorder in its combination of chills, fever, body aches, and absence of sweating. Thus, some commentators, like the Qing-dynasty physician Zhang Bing-Cheng in Convenient Reader of Established Formulas, referred to this pattern as summerheat-wind. This description also draws our attention to factors like air conditioning that can be a major cause of this pattern in contemporary practice.

Xiao Qing Long Tang (Minor Blue Green Dragon Decoction, p. 21) NCCAOM

This formula is basically a combination of two formulas that release the exterior, Ephedra Decoction (ma huang tang) and Cinnamon Twig Decoction (gui zhi tang), together with Poria, Licorice, Schisandra, Ginger, and Asarum Decoction (ling gan wu wei jiang xin tang) (see Chapter 16). It acts to warm the interior and transform thin mucus, and is most often used for acute attacks of wind-cold in cases with chronic thin mucus.

Du Huo Ji Shen Tang (Angelica Pubescens and Sangjisheng Decoction, p. 758) CA, NCCAOM

This formula is commonly used for chronic painful obstruction, especially in the bones and sinews, and is also used in treating atrophy disorder characterized by wasting of the lower extremities. Many physicians substitute Rehmanniae Radix preparata (shu di huang) for Rehmanniae Radix (sheng di huang) because of its stronger tonifying effect on the blood. However, the source text advises to leave out Rehmanniae Radix (sheng di huang) if the patient has a tendency toward loose stools. Because of its ability to tonify and disperse at the same time, the formula has been used more recently to treat a variety of internal medicine conditions ranging from abdominal pain and hepatitis to asthma and impotence. Many contemporary physicians furthermore think that adding herbs to invigorate the blood to this formula enhances its clinical efficacy. This view reflects a tendency, which started in the late Qing era, to place considerable importance on treating blood stasis in cases of painful obstruction. Stagnation of qi and blood had been acknowledged as an important cause in the pathogenesis of painful obstruction for a long time, as the 19th-century writer Lin Pei-Qin explained in the encylopedic Treatment Decisions Categorized According to Pattern: All [cases of] painful obstruction ... intrinsically [develop] from a primary deficiency of protective and nutritive qi. If the pores and interstices are not firm, wind-cold avails itself of [this] deficiency to assault the interior. The normal qi [then] becomes blocked by the pathogens and is unable to disseminate or move. As it lodges and stagnates, the qi and blood congeal and stagnate, which, over time, causes painful obstruction. While Qing-dynasty physicians, including Ye Tian-Shi, emphasized the role of blood stasis in the treatment of chronic pain, Lin Pei-Qin's contemporary, Wang Qing-Ren, launched a full-scale attack on older treatment methods. In a discussion entitled "Painful Obstruction Patterns are Characterized by Static Blood;' included in his seminal Correction of Errors among Physicians, Wang observed: "Generally, [when] one drives out wind-cold or eliminates damp-heat, it becomes even more difficult to invigorate the already congealing blood." This is because the bitter and warming or cooling nature of the herbs used for this purpose dries up the blood and slows down the qi, thus aggravating any preexisting stasis.

Da Qing Long Tang (Major Blue Green Dragon Decoction, p. 11)

This formula is exemplary for realizing a treatment strategy first advocated in the Inner Classic: "For fire [due to] constraint, discharge it" (huo yu fu zhi). The fire referred to in this maxim is the body's own yang qi (also known as the ministerial fire or the fire at the gate of vitality), which has become constrained and thereby changed from physiological qi into pathological fire. Under normal circumstances, ministerial fire warms and disperses body fluids, which in the exterior manifests as physiological sweating. It follows that promoting sweating can therefore also be used to discharge from the body a pathological accumulation or build-up of yang qi. This is what is meant when Zhang Xi-Chun speaks of "transforming heat that has accumulated and built up in the chest into sweat." This strategy is particularly indicated where the accumulation is due to cold. Acrid warming, in this case, not only increases the diffusion of yang qi toward the exterior, it also actively disperses the pathogen from the body. Irritability and restlessness due to yang qi constraint in the interior is thus one of the most important clinical markers for selecting this formula. Symptomatically, such constraint may also be reflected in skin that is burning hot to the touch, up-flushing of heat, a dry nasal passage, or thirst.

Dang Gui Si Ni Tang (Tangkuei For Frigid Extremities, p. 252)

This formula is regarded as a variation of Cinnamon Twig Decoction (gui zhi tang). The source text notes that it is indicated for cold injuring the terminal yin with "extremely cold hands and feet and a pulse that is thin almost to the point of being imperceptible." In Discussion of Medical Formulas, the Qing-dynasty scholar-physician Fei Bo-Xiong explained the connection between the formula and its indication: The terminal yin is the channel [responsible] for storing the blood. Therefore, Tangkuei Decoction for Frigid Extremities (dang gui si ni tang) focuses on harmonizing the nutritive [qi]. It includes Cinnamomi Ramulus (gui zhi) and Asari Herba (xi xin) to harmonize the protective qi. When the nutritive and protective qi are harmonized, frigidity of the extremities resolves by itself. In spite of the presence of cold [as the main pathogen], the formula does not employ Aconiti Radix lateralis preparata (zhi fu zi) or Zingiberis Rhizoma (gan jiang) out of fear that their excessively drying [nature) may cut off yin and consume the blood. Some commentators, however, found it difficult to accept that frigid extremities from cold deficiency might be treated without the use of the warming and dispersing herbs Aconiti Radix lateralis preparata (zhi fu zi) and Zingiberis Rhizoma (gan jiang). The most influential representative of this current, the Qing-dynasty physician Ke Qin, advanced a critique in Collected Writings on Renewal of the Discussion of Cold Damage that demonstrates that even the formulas of sages like Zhang Zhong-Jing were not beyond the reproach of classically-oriented physicians: The pattern [discussed) in this section [of Discussion of Cold Damage] is an interior [pattern]. One should use Frigid Extremities Decoction (si ni tang) as the foundation and add Angelicae sinensis Radix (dang gui). Poria Frigid Extremities Decoction (fu ling si ni tang) is an example [of when this type of modification is permitted]. Using [a variation of] Cinnamon Twig Decoction (gui zhi tang) to attack the exterior [when the illness is in the interior) is wrong. Nevertheless, most commentators agree with Fei Bo-Xiong's interpretation. They view the formula as an example of the versatility of Cinnamon Twig Decoction (gui zhi tang) in treating conditions arising from cold entering the nutritive qi (see Chapter 1). Astragalus and Cinnamon Twig Five-Substance Decoction (huang qi gul zhi wu wit tang), discussed below, Cinnamon Twig plus Aconite Accessory Root Decoction (gul zhi jia fu zi tang), discussed in Chapter 1, and Cinnamon Twig, Peony, and Anemarrhena Decoction (gui zhi shao yao zhi mu tang), discussed in Chapter 16, are other examples. Because the nutritive qi circulates within the vessels, obstruction to its flow frequently manifests as painful obstruction patterns in the extremities. The role of Cinnamomi Ramulus (gui zhi) in all of these formulas is to lead the yang into the yin, the protective into the nutritive, and to facilitate its dispersion and resolve stagnation. The type of frigid extremities disorder for which this formula is indicated-deficient blood and nutritive qi fettered by cold-must be distinguished from other possible manifestations of this disorder.

Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity, p. 167) CA, NCCAOM

This formula is suitable for all types of fire toxin obstructing the three burners. Such patterns are typically characterized by symptoms such as high fever, irritability, a dry mouth and throat, a red tongue with a yellow coating, and a rapid, strong pulse. Most commentators agree that the herbs that comprise the formula have been selected to drain heat and resolve toxicity from different sections of the Triple Burner. However, it is equally possible to think of their combination as a simple additive synergy where substances with the same basic action potentiate their individual effects. This perspective was first suggested by the Ming dynasty scholar-physician Zhang Jie-Bin: There is yin and yang fire, and heat [disorders] can be divided [according to whether they occur) above or below. According to the ancient formularies, Coptidis Rhizoma (huang lian) clears the Heart, Scutellariae Radix (huang qin) clears the Lungs, Dendrobii Herba (shi hu) and Paeoniae Radix (shao yiio) clear the Spleen, Gentianae Radix (long dan cao) clears the Liver, and Phellodendri Cortex (huang bai) clears the Kidneys. Present usage generally adheres to this method. It is also a method of sticking [to custom without adapting to changing circumstance). Generally, cold and cooling substances are all able to drain fire [irrespective of its location]. How could one claim that they cool here but do not cool there? The contemporary formula expert Wang Mian-Zhi makes an interesting point regarding the emphasis on this formula's ability to resolve toxicity. He argues that this originally applied to its use in treating the effects of alcohol abuse. Alcohol is an acrid, dispersing, and strongly heating substance the effects of which are felt all over the body, that is, throughout the entire Triple Burner. In particular, although excess heat is itself a qi-aspect phenomenon, the effects of alcohol are focused on the blood. From this perspective, the present formula is particularly suitable for draining qi-aspect heat that stirs the blood, unlike White Tiger Decoction (bai hu tang), which clears yang brightness heat that has spread throughout the Triple Burner. Furthermore, the aftereffects of alcohol consumption-insomnia, flushes, irritability, focal distention-provide useful clinical markers for using the formula in clinical practice.

Da Huang Fu Zi Tang (Rhubarb and Prepared Aconite Decoction, p. 71)

This formula is the model for all other formulas that warm the yang and purge. It was first listed in Chapter 10 of Essentials from the Golden Cabinet, which deals with the differential diagnosis and treatment of abdominal fullness, bulging disorders, and harbored food. All of these disorders are due to accumulation or stagnation, with pain as the most prominent symptom. The present formula treats a pattern that is characterized by "stubborn pain under the ribs, fever, and a tight and wiry pulse:' Because the ribs correspond to the Liver and the terminal yin, several commentators interpret this pattern as reflecting a Liver disorder. The Qing-dynasty physician Wu Ju-Tong is representative of this group: This [formula treats] a pathogen residing in the terminal yin, where both exterior and interior need urgent attention .... A wiry pulse indicates Liver constraint, a tight [pulse] interior cold. Stubborn pain under the ribs, [the area traversed by] the channels and collaterals of the Liver and Gallbladder, indicates cold and dampness contending. This [leads to] constraint within the blood aspect that manifests as pain. Fever is due to the Liver being constrained. Thus, one employs Aconiti Radix lateral is (fu zi) to warm the interior and unblock the yang, and Asari Radix et Rhizoma (xi xin) to warm the water organ and disperse cold and damp pathogens. The Liver and Gallbladder have no exit passage [of their own]. Therefore, one uses Rhei Radix et Rhizoma (da huang) to supply them with an exit passage via the Stomach [from which accumulation can be eliminated].

Xian Fang Huo Ming Yin (Sublime Formula for Sustaining Life, p. 861)

This formula is used for early-stage yang sores that develop rapidly. Golden Mirror of Medicine describes it as an "exalted medicine for sores, and a premier formula for external disorders." In the source text, Xue Ji wrote that "It treats all kind of sores and carbuncles. It disperses those that have not yet formed and [causes] those that have already formed to burst. ... It is an effective prescription for stopping pain and discharging toxins:' Its composition and efficacy thus make it the flagship formula for what is known as the 'dissipating method' (xiao fa), one of the three basic treatment strategies in Chinese external medicine (see chapter introduction). 'Dissipating' here implies dispersion of internal stagnation in order to treat problems in the exterior, as explained by Ye Tian-Shi in Case Records as a Guide to Clinical Practice: Generally, although external medicine patterns manifest in the exterior, the root of the disorder is located in the interior. If one is clear about yin and yang, excess and deficiency, heat and cold, and the channels, collateral, and every single acupuncture point, one is able to change serious patterns into minor ones, and make minor ones disappear. Those who excel at reducing and dissipating are superior craftsmen. As noted in the chapter introduction, the initial cause of abscesses and sores was identified in Chapter 81 of Divine Pivot as stagnant nutritive qi and blood. This understanding was utilized by later physicians. Zhang Bing-Cheng, for example, wrote in Convenient Reader of Established Formulas: The initial stages of toxic swellings are always caused by the stagnation of nutritive qi and blood. The ensuing constraint [of protective qi] becomes heat. As nutritive and protective qi lose their regular [interconnection,] the disorder acquires form on the outside, hence exterior patterns will be apparent on the outside. Given the close connection between nutritive qi and digestion, an improper diet and the invasion of pathogens via the Spleen and Stomach are the main cause of toxic swellings treated by this formula. This opens up a wide range of conditions beyond the narrow domain of external medicine. Chinese practitioners have thus expanded its application to the treatment of many types of inflammatory disorders that present with blood stasis, phlegm, and heat toxin. When considering the use of this formula in such cases, it is important, first, to ascertain whether the presenting pattern is one of excess. Then, because the formula is strongly cooling, there should also be clear signs indicating the presence of heat toxin such as localized redness and swelling, heat sensations, painful inflammation, a slightly yellow tongue coating, or a rapid pulse.

Run Chang Wan (Moisten the Intestines Pill from Master Shen's Book, p. 80) CA, NCCAOM

This formula may be used in treating many types of constipation associated with debility. Key symptoms suggesting its use are dry stools that are not difficult to pass and a thin tongue with little or no coating. Because its actions are mild, it does not always work quickly but may require extended use for maximum effect. It should not be prescribed in cases that require purging.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

This formula may therefore be used in treating other problems than those described above. Because it enhances the transformation and transportation of fluids, it can be utilized when the Small Intestine fails in its task of separating the clear from the turbid. It is also useful in treating damp painful obstruction, which is characterized by a sensation of heaviness in the extremities and urinary difficulty. Where an accumulation of fluids known as 'pathogenic water' (shui xie) invades the Lungs and causes coughing and wheezing, the use of this formula will promote urination and thereby eliminate the water and relieve the coughing and wheezing. In each case, the pattern will be characterized by the simultaneous occurrence of thirst despite fluid intake, reduced urinary output, a floating pulse, a thin, white, and wet tongue coating, and signs of heat or rebelliousness. In Annotated Fine Formulas from Generations of Famous Physicians, the modern physician Ran Xue-Feng cogently sums up the nature of this pattern and the character of the formula: If one examines this formula, [one notes that] by transforming the qi and moving the water, it stimulates the transformative [functions of the qi] dynamic in a divine fashion. Its extraordinary effectiveness is on a par with that of Cinnamon Twig Decoction (gui zhi tang). ...Qi transforms water and water transforms qi in a continuous transformative dynamic. In case of cold damage [disorders] the qi dynamic becomes constrained and stagnates, and if it does not transform into fire, it will transform into [pathological] water. Water and fire contend with each other. When this happens, the sheen of qi does not moisten and there cannot but be irritability and thirst. In case of the miscellaneous disorders from thin mucus or water qi, there is obstruction from pathogenic water. Where the water does not reach, the qi does not reach; where the qi does not reach, water does not reach. If they rebel to the lower [burner], there are pulsations below the umbilicus. If they rebel to the middle [burner], there is spitting up of frothy saliva. If they rebel to the upper [burner], there is vertigo. Therefore, both Discussion of Cold Damage and Essentials of the Golden Cabinet employ this formula.

San Jin Tang

This formula originated from the Shuguang Hospital of the Shanghai College of Traditional Chinese Medicine and its name can be attributed to the fact that three of the ingredients' names contain the word gold (jin). The specific action of these three herbs-Lysimachiae Herba (jin qian cao), Lygodii Herba (jin sha teng), and Gigeriae galli Endothelium corneum (ji nei jin)-is to dissolve stones in both the urinary and bile tracts. Hence, they are frequently combined for this purpose.

Wu Wei Xiao Du Yin (Five Ingredient Decoction to Eliminate Toxin, p. 863)NCCAOM

This formula serves as the foundation for many formulas that are used in treating localized, superficial, purulent infections. Even though the formula is cold, clears heat, and resolves toxicity, it is nevertheless intended to induce sweating. This is in apparent contradiction to the therapeutic principle formulated by Zhang Zhong-Jing, who said that "It is forbidden to use sweating in patients with sores:' The rationale underlying this principle is that sweating damages the qi and fluids and thereby aggravates the heat and stagnation that are the root of the disorder. On the other hand, Basic Questions (Chapter 70) states that "Once [a patient] sweats, sores go away." This contradiction can be resolved by noting that the sweating induced by this formula is intended to be extremely light, while all of the herbs in the formula are cooling without being excessively bitter or drying. Thus, the qi dynamic is enabled without damaging the qi or blood. The source text notes that the occurrence of the type of hard sores treated by this formula is a serious condition that can readily result in death from what at present is known as blood poisoning. This formula is thus designed not only to treat the manifestations, but also to stop the accumulation and dissemination of toxin. In the clinic, it can be used whenever the four key signs of an inflammatory response-heat, redness, pain, and swelling-are present. This expands the therapeutic scope of the formula to a very wide spectrum of conditions.

Shi Pi Yin (Bolster the Spleen Decoction, p. 749) NCCAOM

This is a representative formula for the treatment of yin-type edema due to Spleen and Kidney yang deficiency. One treats a condition such as this by warming the yang and bolstering the Spleen while simultaneously promoting the water metabolism in order to eliminate the pathogenic water. For this reason, Aconiti Radix lateralis preparata (zhi fu zi) and Zingiberis Rhizoma (gan jiang) serve as the chief herbs in the formula. Zingiberis Rhizoma (gan jiang) warms and promotes the movement of Spleen yang to invigorate the transportive processes in the middle burner, and the Spleen yang's ability to transform and transport water and dampness. It is very hot in nature but is not toxic. Because its action is confined primarily to the middle burner, it is used in almost every case involving a cold, deficient Stomach pattern. Aconiti Radix lateral is preparata (zhi fu zi), on the other hand, is acrid and very hot in nature. It tends to travel throughout the body unblocking and promoting the movement of yang qi in all twelve channels. It also tonifies the fire at the gate of vitality. It is therefore very effective in overcoming stagnation from the accumulation of yin (water). Together, these herbs work synergistically to warm and nourish the Spleen and Kidneys, supporting the yang and curbing the yin. The deputies, Poria (fu ling) and Atractylodis macrocephalae Rhizoma (bai zhu), strengthen the Spleen and resolve dampness by promoting urination. Aromatic Chaenomelis Fructus (mu gua), an assistant herb, revives the Spleen, transforms dampness, and promotes urination to strengthen the Spleen's transporting and transforming functions. The other assistants, Magnoliae officinalis Cortex (hou po), Aucklandiae Radix (mu xiang), Arecae Pericarpium (da fu pi), and Tsaoko Fructus (cao guo), direct the qi downward, guide out stagnation, transform dampness, and circulate the fluid. Arecae Pericarpium (da fu pi) also promotes the movement of qi, promotes urination, and reduces edema. Once the circulation of qi is restored, dampness will be transformed. The envoys, Glycyrrhizae Radix preparata (zhi gan cao), Zingiberis Rhizoma recens (sheng jiang), and Jujubae Fructus (da zao), regulate and harmonize the other herbs, benefit the Spleen, and harmonize the middle burner.

Bai He Gu Jin Tang (Lily Bulb Decoction to Preserve the Metal)

This formula was originally composed to treat consumptive disorders affecting the Lungs that are caused by underlying Kidney yin deficiency. In Collectanea of Investigations from the Realm of Medicine, the Qing-dynasty physician Wang Fu provides a detailed explanation of the strategy underlying its composition: [In Chapter 8 of Basic Questions it states that] the Lungs hold the office of prime minister and are the issuer of management and regulation. Its location close to the Heart makes it innately antagonistic to fire. If Lung metal clarifies and clears [fire] and the five yin organs are calm, [the Lung qi is] not restrained by its [natural] aversion to fire. [Hence, it is able to exercise its charge of] management and regulation in a spontaneous and unhurried manner. Qi is [then] governed and disorders [characterized] by dispersal and rebelliousness will not exist. When the Lungs become deficient [their charge of] management is no longer regulated, and they are incapable of generating qi. Qi rebels and the vessels become chaotic. In such [a situation,] it is appropriate to use sour [herbs and formulas] to restrain [the excess]. However, by their nature, the Lungs have much qi and little blood and are easily impaired by dryness. If a person's Kidney water is exhausted or impaired, the ministerial fire flares upward. Although metal generates water, this is insufficient to triumph over fire. This [is the cause] of Lung consumption. If sovereign fire becomes fearless [because it is] assisted by ministerial fire, [the two] combine, flaring upward and damaging the healthy Lungs. Contrary to the [normal physiological function outlined above, this is a situation] where Lung deficiency arises because of Kidney deficiency and Lung function is overexerted. . .. [In its composition, this formula thus] focuses on controlling fire so that it does not punish metal. Secondarily, it assists metal so that it can generate Kidney water below. This is why the intention [also expressed in the formula's name] is ultimately to preserve metal. In practice, the formula is thus most suitable for treating cases of chronic cough or throat pain accompanied by blood loss: the former indicating yin deficiency, the latter, the uncontrolled upward movement of fire. Once these symptoms have abated, a different strategy should be selected, following the advice of Fei Bo-Xiong, another Qing-dynasty physician, in Discussion of Medical Formulas: "Li Shi-Zai said: 'After clearing metal one must urgently attend to the mother.' This understanding is outstanding. I [therefore] say: 'When the throat pain has been entirely alleviated, one should urgently nurture earth to generate metal.' "

Dang Gui Si Ni Tang (Tangkuei For Frigid Extremities, p. 252)

This formula's focus on the nutritive qi-that aspect of the body's qi that is produced in the middle burner, fills the vessels, and forms the basis for the production of blood-also helps explain the large dosage of Jujubae Fructus (da zao) included in the original formula. According to Li Shi-Zhen, Jujubae Fructus (da zao) is an herb for the "Spleen channel blood level:' Seeking Accuracy in the Materia Medica further explains that it "is sweet so that it tonifies the middle, warm so that it augments the qi. When the Spleen and Stomach are tonified, the twelve channels are naturally unblocked:' Nevertheless, ever since the Jin-Yuan epoch, physicians have reduced the dosage of this herb in this and many other formulas due to concerns about its cloying nature. Practitioners should exercise their own judgment in weighing priorities.

Fang Feng Tong Sheng San (Ledebouriella Powder that Sagely Unblocks, p. 290)

This formula, which some physicians regard as a variation of Cool the Diaphragm Powder (liang ge san), is used for excess heat in both the exterior and interior. It is representative of the strategy of'double releasing' (shuang jie), that is, releasing the exterior while clearing, draining, or purging heat from the interior, which was devised by Liu Wan-Su, one of the great masters of the Jin-Yuan period. Liu argued that "all six [pathogenic] qi can transform into fire" and that special attention should therefore be paid to eliminating it from the body. These ideas later became focal points for the development of warm pathogen therapeutics during the Ming and Qing epochs. Liu Wan-Su thus opened the way for an important transformation in Chinese medicine, as he himself noted: The double-releasing [strategy] that I have constructed in the acrid, cold Sagely Unblocking formula does not follow the model of [Zhang] Zhong-Jing with [reliance on] exterior-releasing herbs like Cinnamomi Ramulus (gui zhi) and Ephedrae Herba (ma huang). It is not that I am showing off, as it contains the [correct] principles. The use of acrid, warm herbs like Ephedrae Herba (ma huang), Saposhnikoviae Radix (fang Jeng), and Schizonepetae Herba (jing jie) to treat wind-heat in the exterior nevertheless distinguishes this formula from the treatment strategies developed later by physicians like Ye Tian-Shi and Wu Ju-Tong. Although their use is moderated by the inclusion of herbs that tonify the blood, in contemporary clinical practice, it would be foolish to ignore the subsequent developments in Chinese medicine that occurred during the centuries that followed. Thus, where aversion to cold is not very pronounced, some modern textbooks, such as Formulas edited by Li Fei, suggest that Ephedrae Herba (ma huang) be removed from the prescription. From the perspective of the six warps of disease, this formula treats a disorder that simultaneously affects the greater yang (exterior), yang brightness (interior heat), and lesser yin (focal distention with a stifling sensation in the chest and diaphragm). The source text recommends the formula for all wind-heat disorders with constipation, dark, rough urination, facial sores, and red, sore eyes, since such conditions can progress to internally-generated wind with stiff tongue or clenched jaw.

Jing Fang Bai Du San (Schizonepeta and Saposhnikovia Powder to Overcome Pathogenic Influences, p. 49)

This is a more severe presentation than that for which the principal formula is indicated, and occurs in those with no underlying qi deficiency. Also for early-stage abscesses or sores that are red, swollen, and painful and accompanied by fever, chills, absence of sweating, thirst, a thin white tongue coating, and a floating, rapid pulse.

Xiao Jian Zhong Tang (Minor Construct the Middle Decoction, p. 264) CA, NCCAOM

This is a popular formula that can be used for a variety of consumptive disorders with yang deficiency. It is the primary formula for treating abdominal pain due to cold from deficiency, characterized by abdominal pain that responds favorably to warmth and accompanied by cold, sore extremities. There should be no signs of heat, such as constipation or yellow urine.lt may also be used in treating jaundice and dysenteric disorders due to cold from deficiency. A second major area of application is pediatrics where it is used to treat a wide range of disorders associated with cold from deficiency. In Japan, it is especially popular for treating enuresis but is also used for sleeping disorders, headaches, allergies, recurrent infections, cramping, and abdominal pain. Important clinical markers for both types of problems include: • A generally weak and debilitated disposition associated with the loss of essence such that the patient looks pale, is easily exhausted, has low resistance to stress of various kinds, feels cold but sweats easily, has a weak back and knees or a variety of aches and pains, and anxiety • Superficial tension of the rectus abdomini muscles, especially in the upper abdomen, in a person with a bloated but weak abdomen, and with no pain on palpation; in children, especially, the peristaltic movement of the bowels may become visible • A tendency to hyperexcitability that can manifest in muscular cramping or tension, pains that come and go or move about, irritability, nervousness, palpitations, excessive dreaming, nosebleeds, and similar symptoms • A pale and tender tongue with various types of coating, from thinnish white and yellow to a more thick white, depending on the nature and degree of constraint accompanying the fundamental deficiency. The ingredients of this formula are the same as those in Cinnamon Twig Decoction plus Peony (gui zhi jia shao yao tang) with the addition of Maltosum (yi tang). This illustrates how the therapeutic focus of a formula may be changed by altering the dosage of the ingredients and their ratio to one another. Depending upon their view of the underlying mechanism, various commentators have designated Maltosum (yi tang), Paeoniae Radix alba (bai shao), or Cinnamomi Ramulus (gui zhi) as the chief ingredient in the formula.

Xiao Yao Wan (Rambling Powder, p. 120) CA, NCCAOM

This is a variation of Frigid Extremities Powder (si ni san), which is widely used in internal medicine and in the treatment of women's disorders. It may be used for any condition with Liver constraint, blood deficiency, and Spleen deficiency characterized by hypochondriac pain, fatigue, reduced appetite, pale-red tongue, and a wiry, deficient pulse. The wide range of applications for this formula is attributed by many physicians to the fact that its composition realizes the three basic treatment principles for Liver disorders listed in Chapter 22 of Basic Questions: 1. "When the Liver suffers from tension, quickly take sweet [flavors] to relax it:' 2. "When the Liver requires dispersion, quickly take acrid flavors to disperse it:' 3. "Use acrid [flavors) to tonify it and sour [flavors) to drain it." From a physiological point of view, the specific characteristic of this formula is its simultaneous treatment of excess and deficiency in both the Liver and Spleen. The modern physician Qin Bo-Wei succinctly analyzed the reasoning behind this strategy: When the Liver and Spleen are both deficient, wood cannot dredge earth. If the Liver is unable to dredge and drain to facilitate an orderly [qi dynamic], if the Spleen is unable to strengthen the transportive functions and generate transformation, the manifestations of constraint take shape .... For this [type of disorder] one cannot simply write out formulas that dredge the Liver. (Medical Lecture Notes of [Qin] Qian Zhai).

Qing jin hua tan tang

This is an important formula for treating phlegm-heat. In can be viewed as a modified combination of Two-Aged [Herb] Decoction (er chen tang) and Minor Decoction [for Pathogens] Stuck in the Chest (xiao xian xiong tang). Its composition can be traced to a similar formula by the Yuan-dynasty master physician Zhu Dan-Xi, who added Scutellariae Radix (huang qin) and Glycyrrhizae Radix (gan cao) to that combination in order to treat phlegm-heat clogging the upper burner. In Essential Teachings of [Zhu} Dan-Xi, Zhu outlined the treatment principle on which this formula is based: "[Most physician] see physical phlegm and treat the phlegm. Expert practitioners do not treat the phlegm, but the qi." This principle was, in turn, a synopsis of an earlier statement by Pang An-Chang, cited in Indispensable Tools for Pattern Treatment: [Under normal conditions,] phlegm in the body does not reach the upper burner just as water does not flow upward in nature. [Accordingly,] experts at treating phlegm do not treat the phlegm, but the qi. Once the qi is normalized the fluids of the entire body follow the qi and are also normalized. This suggests that phlegm is a physiological by-product of the digestive process in the middle burner that is normally dispersed via the bowels as part of the ongoing separation of the clear and turbid that characterizes healthy metabolic activity. It becomes visible only when it is carried around the body by pathogens, such as fire. As explained by Zhang BinCheng in Convenient Reader of Established Formulas: The treatment of phlegm-heat [is discussed by] Wang Ang who said that phlegm-heat disorders are caused by fire. Phlegm [can be regarded as] fire with form, while fire is phlegm without form. Phlegm follows fire as it ascends or directs downward, while fire is guided to move horizontally by phlegm. The r ensuing] mutations produce all kinds of patterns, which are too numerous to be detailed exhaustively. Fire avails itself of the qi [generated by] the five yin organs, phlegm avails itself of the yin fluids [produced from] the five flavors. If the qi is excessive, it becomes fire; if the yin fluids are excessive, they become phlegm. To treat phlegm, one thus must direct this fire downward, and to treat fire, one must smooth the flow of qi. This formula was composed on the basis of these [principles]. Given these considerations, the use of this formula in clinical practice extends primarily to the treatment of productive cough with yellow sputum. This pattern often occurs during wind-warmth disorders when wind has been dispelled from the exterior but phlegm remains and combines with excess internal heat. This often results from the use of acrid, cooling medicinals (including aspirin and similar antipyretics) that succeed in treating the wind but precipitate the transformation of preexisting dampness into phlegm. The formula can also be used to treat warm-dryness disorders where wind has been dispelled but dryness remains, manifesting as a dry painful throat, cough with yellow sputum, and stabbing pains in the flanks. Other possible patterns include damp-heat obstructing the middle burner leading to nausea, vomiting, and other manifestations of rebellious qi; and phlegm-heat obstructing the Triple Burner, causing insomnia and palpitations.

Lian Po Yin (Coptis and Magnolia Bark Decoction, p. 705)

This is one of several formulas for the treatment of sudden turmoil disorders (huo luan) composed by the late 19th-century physician Wang Shi-Xiong. In Chinese medicine the term 'sudden turmoil disorder' refers to acute conditions characterized by the simultaneous onset of vomiting and diarrhea. There are two basic types of this disorder. In the first, known as 'wet sudden turmoil disorder' (shi huo luan), the body attempts to dispel pathological substances from the Stomach or Intestines by means of vomiting or diarrhea. The second type, known as 'dry sudden turmoil disorder' (gan huo luan) or 'bowel-gripping granular disorder' (jiao chang sha), is characterized by abdominal cramping, irritability, restlessness, a stifling sensation, and confusion. The patient feels as if he should vomit or pass stools but cannot do so. This formula (and the others discussed in this chapter) are indicated for the first type. Use of the term huo luim to designate disorders characterized by sudden and intense vomiting and diarrhea goes back at least to the Han dynasty. Zhang Zhong-Jing discussed its treatment in detail in Discussion of Cold Damage, and there are many later discussions in the literature, including those by proponents of warm pathogen therapeutics. In modern Chinese, the term :[ ~L huo luim is used as a translation for the biomedical disease 'cholera: leading many modern physicians to assume that there is an equivalence between sudden turmoil disorders and cholera. In fact, as the historian Kim Taylor has demonstrated, cholera only arrived in China from India in the course of the 19th century. This led to a frantic search for effective treatments. While some physicians went back to the Discussion of Cold Damage and other classical texts, others, like Wang Shi-Xiong, argued that new strategies, specifically those derived from warm pathogen therapeutics, which were still quite recent and by no means orthodox at the time, were required. Attaching these new strategies to an established disorder like huo luan enabled Wang Shi-Xiong to more easily convince others of the potential utility of his ideas. Readers should thus be clear that while Wang Shi-Xiong's formulas most certainly were designed to treat cholera, pre-19th -century formulas indicated for huo luan were not.

Sang Ju Yin (Mulberry Leaf and Chrysanthemum Decoction, p. 35) CA, NCCAOM

This is the classic formula for early-stage warm pathogen diseases or other mild exterior heat disorders in which coughing is the main symptom. It is also used for eye disorders due to wind-heat and hacking cough due to exterior dryness. According to its author, Wu Ju-Tong, the famous systematizer of warm pathogen disorder therapeutics, it can address these different disorders because they all require a dispersing formula that releases obstruction in the exterior without injuring the fluids. For this reason, Wu selected as chief herbs Mori Folium (sang ye) and Chrysanthemi Flos (ju hua), a synergistic combination that relies on subtle manipulation of the qi dynamic rather than merely on acrid opening. Mori Folium (sang ye) specifically acts on the Lung collaterals, which are implicated in the superficial penetration of pathogens into an organ. Both of the chief herbs enter the Liver and Lung channels. While heat pathogens obstruct the clarifying and downward-directing function of the Lung qi, the fire of Liver yang ascends uncontrolled. By clearing heat from both channels, this formula treats root and branch simultaneously. In addition, both of the chief herbs combine sweet moistening with their clearing and dispersing actions. Chrysanthemi Flos (ju hua), in particular, protects the fluids, and by gently nourishing the yin helps to control the excess of yang that is the root of the pathology.

Ma Huang Tang (Ephedra Decoction, p. 7) CA, NCCAOM

This is the classic formula for treating cold excess in the exterior. Its primary focus is to stimulate sweating. It appears at least nine times in Discussion of Cold Damage for treatment of greater yang-warp disorders where the presentation is referred to as cold damage. This is the narrow meaning of the term shang han, the broader meaning of which encompasses all types of cold damage disorders. Commentators differ in their explanation of why Zhang Zhong-Jing, the author of the formula, chose for his chief herb Ephedrae Herba (ma huang) rather than another diaphoretic herb indicated for taiyang disorders. The early 20thcentury physician Zhang Xi-Chun argues that, of all these herbs, only Ephedrae Herba (ma huang) combines all the actions needed to address the various aspects of a cold damage pathology. Besides inducing sweating and opening up Lung constraint, Ephedrae Herba (ma huang) also enters the Bladder and functions as a diuretic. This allows it to push out cold that has already penetrated deeper into the greater yang. Other commentators focus their attention on the interaction of the chief and deputy herbs in the prescription. The most common view is that Ephedrae Herba (ma huang) relieves the constraint of protective qi in the exterior to open the pores and interstices, while Cinnamomi Ramulus (gui zhi) penetrates deeper into the muscle layer and channels to open up areas of stagnation of the nutritive qi, so that pathogens can also be vented to the outside from there. Fang You-Zhi, the influential Qing-dynasty commentator on the Discussion of Cold Damage, goes one step further to argue that the deputy not only enhances the diaphoretic effect of the chief herb, but also checks and controls it. Likening both herbs to generals in battle, Fang notes that Ephedrae Herba (ma huang) "is like a powerful general who smashes through the enemy lines in order to detain the foe." By contrast, Cinnamomi Ramulus (gui zhi) acts "like a military advisor who plans strategies from within his command tent:' Viewed from this perspective, ensuring the harmonious interaction of protective and nutritive qi emerges as the ultimate objective of Ephedra Decoction, just as it does for the better known Cinnamon Twig Decoction, discussed below. Harmonious and balanced, however, does not mean mild, and the Golden Mirror of the Medical Tradition calls Ephedra Decoction "[Zhang] Zhong-Jing's fiercest medicine for opening the exterior and driving out pathogens by inducing sweating:' Another famous commentator on the works of Zhang Zhong-Jing, Ke Qin, likewise explains that " [this] is a purely yang formula, which only discharges and disperses. Like a commander who comes straight to the point, it does only what is appropriate and [thereby] achieves victory with one single battle .... Therefore, one can use it to release the exterior, but one must [use it only once] and not repeatedly." Given the potentially adverse effects of such a potent formula, a healthy respect gradually turned into outright suspicion and fear among physicians and patients in late imperial China, who increasingly avoided its use. This attitude was especially prevalent among the proponents of the warm pathogen disease current and the population of the lower basin of the Yangzi River, where this style of practice was most influential. In view of some of the problems facing practitioners in many Western countries regarding the use of Ephedrae Herba (ma huang), alternative formulas composed in the wake of such anxieties-particularly Augmented Cyperus and Perilla Leaf Powder, discussed later in this chapter-are of undoubted value. They should not distract, however, from the real value of Ephedra Decoction in the treatment of cold damage disorders.

Yin Qiao San (Honeysuckle and Forsythia Decoction, p. 36) CA, NCCAOM

This is the classic formula for treating protective-level warm pathogen diseases. Its unique value lies in its integration of three distinctly different strategies: vent wind-heat from the exterior; clear heat from the Lung collaterals and resolve toxicity; and prevent the sinking inward of pathogens into the Pericardium or middle burner. This may appear unproblematic to us now. But a look at the formula's genealogy shows that its composition marked a distinctive breakthrough in the treatment of warm pathogen disorders by Chinese medicine; so much so, in fact, that its precise structure and mode of action is still being debated today.

Ping Wei San (Calm the Stomach Powder, p. 687) CA, NCCAOM

This is the most representative and popular formula for the treatment of dampness stagnating in the middle burner. The cardinal symptoms are distention and fullness in the epigastrium and abdomen, and a thick, white, and greasy tongue coating. These symptoms imply that the primary pathology is obstruction of the qi dynamic by dampness. The most appropriate strategy for resolving this problem is to guide out obstruction and open the qi dynamic. Once the qi is regulated, any remaining dampness will naturally be transformed, as explained by Fei Bo-Xiong in Discussion of Medical Formulas: Calm the Stomach Powder (ping wei san) is a sagely formula for treating the Spleen and Stomach. It facilitates the resolution of dampness, transforms focal distention, disperses distention, and harmonizes the middle. It also treats unseasonal epidemics [due to] miasmatic qi. It is drying but not violently [so]. Hence, it is the primary formula for reducing and guiding out. If, as Fei Bo-Xiong suggests, the primary intention of the formula is to guide out excess and fullness in order to open the qi dynamic, the many diverse uses for which the formula has been employed over the centuries are more easily understood. Besides the treatment of various digestive disorders, these include amenorrhea, the facilitation of labor, insomnia, chronic cough, coronary artery disease, male impotence, and damp-type eczema. There has long been a debate in the literature about whether the dampness for which this formula is intended is primarily due to excess (as described above) or to Spleen deficiency. Most commentators have argued that if the formula were designed to treat dampness due to Spleen deficiency, Atractylodis macrocephalae Rhizoma (bai zhu), which is better suited for strengthening the Spleen, would have been used in place of Atractylodis Rhizoma (cang zhu).

Shen Ling Bai Zhu San (Ginseng, Poria and Atractylodes Macrocephala Powder, p. 314) CA, NCCAOM

This variation of Four-Gentlemen Decoction (si jun zi tang) is used when diarrhea and vomiting are the main symptoms or for chronic cough with copious sputum due to Lung deficiency. This is known as 'cultivating the earth [Spleen] to generate metal [Lungs].' It achieves its effect by focusing on the ascending and downward-directing functions of the greater yin, tonifying the qi to raise the clear yang, and eliminating turbid yin by promoting the water metabolism. The use of Platycodi Radix (jie geng) in the formula is particularly important in this respect and has been hugely influential on subsequent generations of physicians. Its action is described in Feng's Secret Records from the Brocade Purse: "Platycodi Radix (jie geng) enters the Lungs. It can ascend as well as direct [the qi] downward. Consequently, it connects the qi of heaven with the pathways of the earth so that one need not worry about obstruction:' The same sentiments are echoed by Wang Ang in Medical Formulas Collected and Analyzed: "Platycodi Radix (jie geng) is sweet and bitter, entering the Lungs. It is able to carry all herbs upward to float. It also can connect the qi of heaven with the pathways of the earth, allowing the qi to ascend and descend, augmenting as well as harmonizing [the qi dynamic]:' Said to be "like a boat that can lift other herbs upward" so as to focus the action of the entire formula on the upper burner, Platycodi Radix (jie geng) thus enhances the effectiveness of the formula in two important ways. First, it directs qi tonification toward the Lungs, where it more effectively moves the qi and thereby the fluids within the body. Second, by focusing the formula's action on the upper burner, it facilitates the ascent of the clear yang. When the clear yang rises, the turbid yin naturally descends. Were this focus lacking, the many dampness-draining herbs in the formula might readily further imbalance the functions of an already weakened middle burner. But in combination with Platycodi Radix (jie geng), they guide out dampness without injuring the qi. The formula's focus on preserving as well as augmenting the qi is underscored by the inclusion of Dioscoreae Rhizoma (shan yao) and Nelumbinis Semen (lian zi) as deputies. Dioscoreae Rhizoma (shan yao) not only tonifies the qi of the Spleen and Lungs, but also that of the Kidneys, enhancing their function of securing and holding. It is a major herb for the treatment of diarrhea, urinary frequency, and spermatorrhea. Similarly, Nelumbinis Semen (lian zi) tonifies the Spleen and Kidneys to stop the diarrhea and stabilize the essence. Thus, even as it drains turbid dampness, the formula prevents the leaking of yin essences. For this reason, this formula is traditionally prescribed to treat diarrhea at the onset of menstrual flow, or leukorrhea (considered by many to indicate a leaking of essences) in relatively obese women with edema and other signs of Spleen deficiency with dampness. More recently, this usage has been expanded to the treatment of chronic proteinuria in patients with edema and signs of qi deficiency. Given its emphasis on the use of bland and neutral rather than acrid and warm herbs, some physicians go even further and view the formula as tonifying not just the Spleen qi, but also the Spleen yin. The contemporary physician Ding Xue-Ping explains: The Ming writer Hu Shen-Rou states in Five Texts by [Hu] Shen-Rou: '[Herbs with a] bland [flavor] nourish the Stomach qi, [those] that are slightly sweet nourish the Spleen yin. This is the secret of success in treating deficiency and consumption .'Whoever has not fully comprehended the secret to the successful recovery from deficiency and injury can arrive there [by way of these words]. The nature and taste of Ginseng Radix (ren shen),Atractylodis macrocephalae Rhizoma (bai zhu), Poria (fu ling), and Glycyrrhizae Radix (gan cao) are balanced. Calmly and gently, they augment the qi to strengthen the Spleen. La blab Semen album (bai bian dou), Dioscoreae Rhizoma (shan yao), Nelumbinis Semen (lian zi), and Coicis Semen (yi yi ren) all have a sweet and bland flavor. They are excellent [herbs] for nourishing the Spleen yin. After any illness or after birth when the body is deficient and has not recovered [its former strength], or where the Spleen yin has been damaged by vomiting or diarrhea, administering [this formula] is always appropriate. [The composition of this formula] truly helps us comprehend the basic principle of deficiency, and is a guide to treating harm.

Da Cheng Qi Tang (Major Order the Qi Decoction, p. 63) CA, NCCAOM

Throughout the history of Chinese herbal medicine, this formula has served as a model for the development of new formulas. The new formulas have extended the scope of purgative treatment strategies to warm pathogen disorders, deficiency conditions, and modern emergency Chinese medicine. Some of the new formulas appear later in this chapter, while others are found in Chapter 13 on regulating the blood and Chapter 15 on treating dryness. There has been considerable debate among physicians regarding the chief herb in this formula. Ke Qin, who emphasized its qi-regulating aspects, argued that Magnoliae officinalis Cortex (hou po) and Aurantii Fructus immaturus (zhi shi) were the most important herbs. This, he believed, explained the large dosage of these herbs in the formula. The opposite view is represented by the Qing-dynasty physician Zou Shu, who argued in Commentary on the Classic of Materia Medica that because Rhei Radix et Rhizoma (da huang) is the only herb contained in all of the various Order the Qi Decoctions (cheng qi tang), it must be the chief herb. Qi is the leader of blood, thus blood follows the movement of qi. This includes [becoming static] when qi stagnates. If qi stagnates and blood does not follow this stagnation [to become static too], then this is because [to begin with] qi is insufficient rather than excessive. In cases of [true] qi stagnation, [such stagnation always] spreads to the blood. The qi then uses the blood like an underground lair [where it escapes attack from qi-regulating herbs], while the blood uses the qi [at which treatment is directed, like a shield for] resisting attack [on itself]. If [such stagnation] is further connected to harbored food, it steams the body fluids, completely transforming [qi into] fire. At such a time, only Rhei Radix et Rhizoma (da huang) can directly purge the core of the disorder, pouring out [the problem from] the underground cave [in which it was hiding]. Once the clumping of qi has been dispersed from the blood,Aurantii Fructus immaturus (zhi shi) and Magnoliae officinalis Cortex (hou po) can successfully carry out their task of opening the qi [dynamic]. This is how Rhei Radix et Rhizoma (da huang) orders the qi.

Wu Ling San (Five Ingredient Powder with Poria, p. 724) CA, NCCAOM

To summarize, the following four pointers are key to the successful use of this formula in the clinic: 1. The presence of excess water and fluids manifesting as outright edema or as thin, watery mucus, a swollen tongue body with slippery tongue coating, reduced urination relative to the intake of fluids, dizziness, etc. 2. Up-rushing of qi that is usually only subjectively experienced by the patient and that can also lead to symptoms such as sensations of fullness or obstruction in the chest, throat, or abdomen. In severe cases, there may be actual pain including headache, or coughing and wheezing. This can also be reflected in a superficial and large pulse. 3. A sensation of heaviness or fuzziness in the head indicating that the turbid is not descending and being eliminated from the lower burner. 4. Up-flushing of heat into the face and upper body due to yang qi separating from yin water. The 'flushing' nature of this heat distinguishes this symptom from the floating yang of yang deficiency disorders, which tends to be continuous in nature and is also accompanied by signs and symptoms of true cold.

Si Ni Tang (Frigid Extremities Decoction, p. 274) CA, NCCAOM

Wang Zi-Jie emphasizes that frigid extremities is the chief indicator for this formula. According to the Qing-dynasty physician Fei Bo-Xiong, the arms must be cold up to (or beyond) the elbows and the legs up to (or beyond) the knees to warrant use of this formula. This type of disorder is called 'inversion rebellion' (jue ni) or 'frigid extremities' (si ni). Classical texts describe three types of inversion (jue) disorders: emotional problems accompanied by a sensation of qi rushing upward from the abdomen to the chest; sudden fainting; and extreme cold in the extremities. This formula is indicated only for the last type of disorder. Furthermore, while the character ni often refers to a contrary flow of qi, as in rebellious qi, the term si ni or 'four rebellions' refers to the symptom of frigid extremities, which here is due to yang qi deficiency and internal cold. The second most important symptom, according to Fei Bo-Xiong, is the pulse, which must be submerged and thin and faint. The modern physician Cheng Men-Xue concurs. In Formulas in Verse from the Scholar's Studio in Two Volumes, he advises: "Whenever one sees a pulse that is faint and thin [in a patient who is also]lethargic with a constant desire to sleep, this is the manifestation of deficiency cold. You should be decisive in [selecting this formula] without hesitation so that later you do not regret having wasted an opportunity [for successful treatment]:' Note that the pulse here appears to be thin because it is so weak. This is different from the pulse associated with Tangkuei Decoction for Frigid Extremities (dang guf sl nl tang) patterns, discussed above, which can be so thin as to become almost imperceptible. The root in the first case is devasted yang unable to invigorate the blood, while in the second, it is deficient blood invaded by cold.

Zhen Wu Tang (True Warrior Decoction, p. 744) CA, NCCAOM

Water is a yin pathogenic factor that requires the assistance of yang in order to be properly transformed. In this case, the source of yang in the gate of vitality must be strengthened in order to reduce the diffusion of yin. Although water is governed by the Kidneys, it is also controlled by the Spleen. Thus, in addition to warming the Kidney yang, one must also address its manifestations (the retention of water and dampness) by using herbs that strengthen the Spleen and benefit dampness. From a six-warps rather than organ-based perspective, this formula focuses on lesser yin patterns characterized by yang deficiency and water flooding. Lesser yin-warp disorders are characterized by fatigue and lethargy as well as a faint, thin pulse that indicates that the yang qi is failing to move and transform the yin. These symptoms should therefore be present in all patterns treated by this formula. They will be accompanied by symptoms reflecting the flooding of water. In Chinese texts, such flooding is also referred to as water qi (shui qi). Like qi, water penetrates everywhere in the body, hence the symptoms can also occur anywhere. This makes the formula useful for a wide spectrum of potential applications.

Zhu Ye Shi Gao Tang (Lophatherus and Gypsum Decoction, p. 155) NCCAOM

When treating a patient who has had a febrile disease, it is very important to ascertain whether the pathogenic influence has in fact been cleared from the body. Lingering of the pathogenic influence in the qi level is a very common problem for which this formula is quite useful.

Qing Wen Bai Du Yin (Clear Epidemics and Overcome Toxin Decoction, p. 179) NCCAOM

Yu Lin stated that Gypsum fibrosum (shi gao) alone is insufficient to treat such disorders. At the same time, it is the only substance capable of clearing heat from everywhere within the body. If qi-level heat is cleared, it is much easier to treat heat at other levels. Due to the strong nature of the heat pathogen, Yu advocated the use of a very large dosage of Gypsum fibrosum (shi gao). This has caused much controversy among later physicians. The Qing-dynasty physician Zhuang Zhi-Ting, cited in Warp and Woof of Warm-Heat Pathogen Diseases, argued that a dosage of 15-90g was sufficient. The modern physician Jiao Shu-De, however, contends that doses of as much as 150-180g are frequently necessary. Wang Shi-Xiong, Yu Lin's great admirer, argued that there was no single, one-size-fits-all dosage, but that it was the nature of the particular disorder that determined the extent of medical intervention. Severe heat requires a severe response, and thus there was nothing wrong with Yu Lin's advocacy of using a very large dosage of heat-clearing herbs.

San Ren Tang (Three Seed Decoction, p. 699)

Wu Ju-Tong is cited at length because he discusses the three most common types of misdiagnosis for damp-warmth disorders: cold damage at the greater yang warp, clumping in the middle burner, and yin deficiency. These are related to the three treatment methods-sweating, purgation, and tonification of yin-that are most strongly contraindicated in the treatment of damp-warmth disorders. An examination of case histories of famous physicians demonstrates, however, that exceptions to this general rule do exist. When dampness obstructs the exterior or channels, for instance, acrid herbs like Pogostemonis/ Agastaches Herba (huo xiang), Notopterygii Rhizoma seu Radix (qiang huo), or Atractylodis Rhizoma (cang zhu) may be used. Or again, when dampheat consumes the body fluids in the Intestines and causes internal clumping, it may be essential to use a purgative formula to open this obstruction. Finally, when damp-heat damages the body fluids, it may be appropriate to combine herbs like Glehniae/Adenophorae Radix (sha shen), Ophiopogonis Radix (mai men dong), Polygonati odorati Rhizoma (yu zhu), or Phragmitis Rhizoma (lu gen) with formulas that facilitate water metabolism. Still, at the stage of the disorder for which this formula is appropriate, all of these strategies are contraindicated. Although a relatively new formula in the context of Chinese medicine's long history, this formula quickly established itself as a classic in its own right. Its importance beyond actual clinical usage lies in its embodiment of the very essence of treating damp-warmth disorders. Precisely because it focuses on facilitating the qi dynamic and on enabling "the transformation of qi so that dampness is also transformed;' this formula is nowadays employed for the treatment of internal damp-heat as well. Thus, contemporary physicians use this formula for an extremely wide range of conditions including insomnia, tinnitus, night sweats, diarrhea, ear infections, skin disorders, and painful obstruction. In clinical practice, this formula thus provides an effective treatment strategy for a wide range of internal and external conditions due to damp-warmth or damp-heat at the qi level, where dampness is more pronounced than heat. The following key symptoms are indicative of such problems and should therefore be present: a stifling and heavy sensation in the chest, afternoon fever, fatigue, a body that feels heavy, discomfort in the epigastrium and abdomen, a white, greasy tongue coating, and a soggy pulse.

Yin Qiao San (Honeysuckle and Forsythia Decoction, p. 36) CA, NCCAOMYin Qiao San (Honeysuckle and Forsythia Decoction, p. 36) CA, NCCAOM

Wu Ju-Tong's intention was thus clear. Nevertheless, later commentators still disputed precisely how this was realized within the structure of the formula. The modern physician Qin Bo-Wei represents one distinctive perspective. To Qin, it seemed logical that since the focus of the formula was on the exterior, the chief herbs should be those that release the exterior, namely Sojae Semen preparatum (dan dou chi), Menthae haplocalycis Herba (bo he), and Schizonepetae Spica (jing jie sui). Yet it was Lonicerae Flos (jin yin hua) and Forsythiae Fructus (lian qiiw) for which the formula was named. Qin believed that Wu Ju-Tong did this to alert practitioners to the fact that cold herbs should be the primary constituents of formulas that treat the early stages of warm pathogen disease. Most other commentators think that the herbs which gave the formula its name are also its chief ingredients. Yet the issue raised by Qin Bo-Wei is more profound. It addresses not only the question of why Wu Ju-Tong thought it necessary to add acrid and warm herbs to a formula that seeks to resolve fire toxicity, but also whether-as in cold damage disorders sweating is a desired and, indeed, necessary outcome of treating warm pathogen disorders at the protective level. In Discussion of Warm Pathogen Heat [Disorders], Ye Tian-Shi stated that a pathogen "at the protective [level] can be [resolved] by sweating:' Some commentators take this to indicate that sweating is the actual goal of treatment at the protective level. It dispels pathogens to the outside, explains Wu Ju-Tong's inclusion of Schizonepetae Spica (jing jie sui) and Sojae Semen praeparatum (dan dou chi), and even supports Qin Bo-Wei's analysis. Others, like Qin's contemporary Zhao Shao-Qin, a well-known expert on warm pathogen diseases from Beijing, dispute this view. He argues that the real goal of treatment at this level is to reestablish the unhindered circulation of protective yang throughout the exterior through a combination of acrid and aromatic dispersal and cool clearing. Sweating may occur as a result of this process, as the protective qi is released from its constraint, but it is not necessary for the treatment to be successful. These apparently opposing views can be reconciled in the clinic by paying close attention to the precise conjunction of signs and symptoms and adjusting the formula accordingly. Where the constraint of protective yang by windheat is marked-indicated by chills, an absence of sweating, and itching in the throat-Schizonepetae Spica (jfng jie sul) ensures that the pathogen is vented to the outside, a process usually accompanied by sweating. If, on the other hand, chills are completely absent, the patient is already perspiring, there is thirst, and the throat is visibly inflammed-all signs that the heat has already entered the qi or even the nutritive level- Schizonepetae Spica (jing jie sui) should be used with more circumspection. Scrophulariae Radix (xuan shen) is one herb that was already recommended in some passages of the source text to be added for just this type of problem. To achieve the best results from using this formula, it is advisable, in any case, to modify and adjust it to the multitude of permutations with which early stage warm pathogen diseases present in the clinic. If physicians belonging to the warm pathogen disease current in Chinese medicine had one thing in common, it was this style of practice: to think of formulas as models of action rather than prescriptions that had to be followed.

Sang Xing Tang (Mulberry Leaf and Apricot Kernel Decoction, p. 665) NCCAOM

Ye Tian-Shi's linkage of wind-warmth and warm-dryness disorders with the seasonal movements of qi within and outside the body provides a dynamic perspective for the understanding of these disorders that goes beyond modern textbook presentations, where pathogens are treated as entities that possess distinctive qualities. Wind-warmth in spring occurs because the warm yang qi in the body that seeks to rise upward and outward is fettered by cold in the exterior, which is contracted during the winter. Warm-dryness represents a movement into the body of pathogenic qi that follows the spontaneous movement of autumn, and that can easily penetrate into the body because the pores are still open. Once inside, it leads to constraint that transforms into heat and damages the fluids, which already tend to be deficient because they have been depleted by summer-heat. Thus, this formula not only releases the exterior, but also opens constraint in the interior and generates the fluids of both Lungs and Stomach.

Da Huang Fu Zi Tang (Rhubarb and Prepared Aconite Decoction, p. 71)

Yet another interpretation is advanced by the early 20thcentury expert of classical formulas, Cao Ying-Fu. In Elaborating on the Subtleties of the Golden Cabinet, Cao argues that the underlying problem is one of water qi or thin mucus accumulating under the ribs: How does one know that stubborn pain under the ribs is [due to] cold water congealing and clumping? Fever [makes this problem] resemble a pattern [where the pathogen resides in the] exterior. How does one know that one must drain downward? Anyone diagnosing such a disorder must know [the answer] for certain. [The area] below the ribs pertains to the Kidneys. It is a key point [of transmission] for the waterways in the middle and lower burner [because the fluids return from the Lungs in the upper burner via the Stomach and Intestines located below the ribs to the Bladder and Kidneys] ... If the waterways are obstructed at this key point, there is pain below the ribs .... If yin cold seizes the interior, floating yang oversteps [its bounds] in the exterior. If yin cold is not broken, the solitary yang [in the exterior] cannot return to its source in the gate of vitality [causing fever] .... The formula employs Aconiti Radix lateral is (fu zi) and Asari Radix et Rhizoma (xi xin) to dispel cold and direct rebellious [yang] downward, to move water, and stop pain. Furthermore, it relies on Rhei Radix et Rhizoma (da huang) to facilitate [this downward movement]. In this manner, the congealing and stasis of water is broken up and the waterways below the ribs are unblocked. The Inner Classic says: pain indicates that something is blocked. Is this [not always] so?