A Cháihú jiā lónggǔ mǔlì tāng case – Huáng Huáng

Wang, 58-year-old male, 186cm/64kg. 

Initial consultation on June 11, 2019. 

History: Patient had a history of stomach disease for over 30 years, accompanied by an inability to eat much food, stomach distention following meals, poor appetite, no desire to eat, coldness in the lower abdomen, a fear of cold, constipation, difficulty falling asleep, and a shallow, dream-disturbed sleep.  

Lab results: Gastroscopy on May 2, 2019, which revealed intermediate chronic atrophic gastritis with intestinal metaplasia in the lesser curvature of the gastric antrum and mild chronic atrophic gastritis with intestinal metaplasia in the greater curvature of the gastric antrum.  

Signs: Sallow complexion, distinct abdominal pulsations, a long face, indifferent expression, slightly thin build, red tip of the nose, and a thin-slippery pulse. 

Prescription:

Bupleuri Radix (chái hú) 15g, Scutellariae Radix (huáng qín) 10g, ginger-fried Pinelliae Rhizoma praeparatum (jiāng bàn xià) 10g, Codonopsis Radix (dǎng shēn) 15g, Cinnamomi Ramulus (guì zhī) 10g, Poria (fú líng) 15g, prepared Rhei Radix et Rhizoma (zhì dà huáng) 5g, Fossilia Ossis Mastodi (lóng gǔ) 15g, Ostreae Concha (mǔ lì) 15g, Zingiberis Rhizoma (gān jiāng) 5g, Jujubae Fructus (dà zǎo) 20g; 10 packets, 1 packet for 2 days. Taken right before bed. 

Second consultation on July 2, 2019: Patient now had a desire to eat, daily bowel movements, and decreased coldness in his lower abdomen. If he overate then he experienced abdominal distention, still had a fear of cold, woke easily due to a dream-disturbed sleep, and was fatigued. 

Prescription 1: Same formula; 1 packet to be taken over 2 days. 

Prescription 2: Bupleuri Radix (chái hú) 15g, Paeoniae Radix alba (bái sháo) 15g, Aurantii Fructus (zhǐ ké) 15g, Glycyrrhizae Radix (gān cǎo) 5g, dried Lilii Bulbus (bǎi hé gān) 30g; 10 packets of each, to be taken on an alternating basis. 

What is a Formula Presentation 方证?

The formula presentation is a theoretical model of herbal formula application that lies between the herbs and formulas on one hand, and the disease pattern on the other. It is the arrow aiming for the target in relation to disease treatment. The formula presentation is the guiding principle behind how a formula is selected. ‘Zheng’(证) refers to evidence, proof, results or efficacy (证验), and also symptoms (症状). Therefore, when all these definitions are taken together, the formula presentation refers to a formula’s key presentation, or instance where a formula displays its main efficacy or results.

Currently in China, many consider the earliest recording of this concept to be found in the Wu Shi Er Bing Fang (五十二病方, Prescriptions for Fifty-Two Diseases), yet many scholars believe that it wasn’t until Zhang Zhongjing’s (张仲景) writings that the concept really took hold, only to be further developed by later generations of physicians. The idea of a formula correspondence (方证相应) is seen in the postscript for line 317 of the Shang Han Lun (伤寒论, Treatise on Cold Damage) which states:

[Only when] the disease corresponds to the formula [can the formula] be taken.

病皆与方相应者,乃服之。

This line offers the most succinct explanation and definition of a formula presentation and implies that all diseases have a corresponding formula, a ‘formula presentation.’ The Shang Han Lun also refers to specific ‘herb presentations’ (药证) such as a ‘Chai Hu (Bupleuri Radix) presentation’ (柴胡证), or a ‘Gui Zhi (Cinnamomi Ramulus) presentation’ (桂枝证). In addition, line 16 of the Shang Han Lun states: 

Observe the pulse and signs, know what error [you] have committed, [and then] treat according to the signs. 

观其的脉证,知犯何逆,随证治之。

The Shang Han Za Bing Lun (伤寒杂病论, Treatise on Cold Damage and Miscellaneous Diseases) was arguably the first text to suggest not just the concept of a formula presentation, but also the principle that became known as ‘determining treatment by patterns identified’ (辨证论治), which lays importance on not just simply knowing which formula treats specific signs, but also on having a clear understanding of the underlying pathomechanism involved. Once the pattern is clearly understood, the choice of the correct formula can be made. According to Professor Huang Huang (黄煌教授), once a formula presentation is clearly identified, not only will the formula be safe to use, but the treatment will also be effective. Following Zhang Zhongjing, physicians such as Sun Simiao (孙思邈), Zhu Gong (朱肱), Xu Lingtai (徐灵胎), Ke Qin (柯琴) and Yu Jiayan (喻嘉言) were highly influential in the ‘school of formula types’ (方类证派), adhering to the concept of ‘formula presentations with similar clauses’ (方证同条).  Song dynasty Zhu Gong referred to a formula presentation simply as a ‘herb presentation.’ The Japanese physician Todo Yoshimasu (吉益东洞) was a strict adherent to the model laid out by Zhang Zhongjing, and was a major contributor to the Japanese Classical Formula School (日本古方派). Although many of these physicians adhered to the formula presentation model, there are some differences in their overall approach and in the method with which they arrived at the presentation. For example, Ke Qin wrote: “Patterns are differentiated from the conformations, therefore the pattern is named after the formula” (证从经分,以方名证), referring to the six conformations (六经), while Xu Lingtai wrote: “In order to [determine] the formula presentation type, [one must] not differentiate according to the conformations” (以方类证,方不分经). While both used the formula presentation model as their method to choose a formula, Ke Qin recorded signs and symptoms exactly as they appear in the Shang Han Lun’s six conformations, while Xu Lingtai worked with general signs and symptoms.  Essentially, a formula presentation is experience: the experienced usage of herbs and formulas over thousands of years. 

Chén Xiūyuán on Gùi Líng Wǔ Wèi Gān Cǎo Tāng

桂苓五味甘草湯
Guì Líng Wǔ Wèi Gān Cǎo Tāng
Cinnamon Bark, Poria, Schisandra, and Licorice Decoction

治青龍湯下已, 多唾口燥, 寸脈沉, 尺脈微, 手足厥逆, 氣從少腹上衝胸咽, 手足痹, 其面翕熱如醉狀, 因復下流陰股, 小便難, 時復冒者, 與此湯, 治其氣衝。

A treatment for when after taking xiǎo qīng long tāng there is copious spittle, a dry mouth, a deep pulse at the inch opening and a faint pulse at the cubit position. [In addition] there is reverse counterflow in the hands and feet, qi surging up from the lower abdomen to the chest and throat, impediment in the extremities, a red flushed face as if drunk, and because of repeated downpour into the groin, there is difficult urination, and periodically recurring muddledness. Give this decoction to treat the surging qi.

按: 脈沉微, 支厥痹, 面如醉, 氣衝時復冒, 似少陰陰陽不交之症, 學者可於臨症時參辨之則可。

Commentary: [When there is] a deep and faint pulse, propping [rheum] with reversal impediment,
a face as if drunk, and qi surging with periodic muddledness, this resembles a pattern of
non-interaction between the yīn and yang of shaoyīn. When arriving at these patterns, students can
compare and differentiate these principles.

Guì Zhī 4 liǎng 桂枝
Fú Líng 4 liǎng 茯苓(各四兩)
Wǔ Wèi [Zǐ] 五味[子] 1/2 shēng(半升)
Zhì Gān Cǎo 3 liǎng 甘草(三兩, 炙)

上四味, 以水八升, 煮取三升, 去滓, 分溫三服。

Simmer the four ingredients above in 1,600ml of water, until reduced to 600ml. Remove the dregs, divide, and take warm in three doses.

Song歌曰:

青龍卻礙腎元虧,
腎元虧而誤服之,
則動衝任之火,
致變為已下諸証。
上逆下流又冒時;
氣從少腹上衝胸咽,
或面熱如醉,
或熱氣流於兩股,
或小便難而昏冒,
忽上忽下,
在陽無主,
如電光之閃爍無定,
味用半升苓桂四,
甘三扶土鎮衝宜。

Xiǎo Qīng Lóng Tāng may cause (further) depletion to the original (qì) of the kidney.
(Original kidney qi was debilitated, and (Xiǎo Qīng Lóng Tāng) was erroneously administered.  
This led to the stirring and surging of conception vessel fire,
which changed into one of the various patterns (which follow) administration].
Ascending counterflow with downpour, in addition to periodic muddledness,
[qi surging upward from the lower abdomen into the chest,
or a red flushed face as if drunk,
or warm qi flowing into the groin,
or difficult urination, and clouded veiling,
which fluctuate sharply, are (the result) of yáng not ruling,
and is unpredictable like the flickering of lightening].
100ml of wǔ wèi zǐ, twelve grams of fú líng and guì zhī,
and nine grams of gān cǎo, are suitable to support earth and settle the surging.

Commentary by (Chén) Yuánxī 男元犀按:

仲師五味子必與乾薑同用, 獨此方不用者, 以誤服青龍之後衝氣大動, 取其靜以制動, 故暫停不用也。 尤雲: 苓、 桂能抑衝氣使之下行, 然逆氣非斂不降, 故以五味之酸斂其氣, 土厚則陰火自伏, 故以甘草之甘補其中也。

Master (Zhàng) Zhōng Jǐng’s wǔ weì zǐ is always combined with gān jiāng (however) in this formula (gān jiāng) is not used. Following the erroneous administration of Xiǎo Qīng Lóng Tāng, there is major stirring of surging qì.  Take this (formula) to tranquilize in order to control the stirring, and once it stops, there is no need to (continue) taking it.  Yóu Zàijīng says: fú líng, and guì zhī are able to control surging qì allowing it to move downwards, and (if) counterflow qì fails to go down due to a lack of restraint, sour wǔ wèi zǐ is used to restrain it. (Once) earth is thickened, yīn fire will conceal on its own, and for this reason sweet gān cǎo is used to supplement earth.

Cáo Yǐngfǔ on the Use of Xiǎo Jiàn Zhōng Tāng 

Master Cao was a pivotal force in the classical formulas school (经方派) and was a true master in using the underlying principles and formulas found in the Shang Han Lun and Jin Gui Yao Lue. Master Cao felt that the medical texts, which followed were too insignificant to study and discuss, and therefore he attached great importance to the thorough study of these texts to his students, and felt that Zhang Zhongjing’s theories and formulas were the perfect framework for successful medical practice. In addition to being skillfully versed in these medical canons, Cao Yingfu was also an accomplished poet, often interweaving the two when attempting to convey his thought process in clinic, often instructing his students to compose a poem and matching it with a relevant line from the classics. This kind of inquiry and thought process truly shows the breadth of his skill and how his mind rarely waivered from the classical Chinese medicine concept of the human body being a reflection of his environment, the microcosm of the macrocosm.
However, master Cao was not completely strict in his formula choices and would often use formulas like Bu Zhong Yi Qi Tang, Xiao Yao San, and Liu Wei Di Huang Wan, in addition to herbs such as niu bang zi, qian hu and various others. This shows that he was obviously well read and did not quickly write off more modern formulas. His use of these non Zhang Zhongjing formulas displayed his deep understanding in the formula constructions and where they were applicable. He advocated that students must understand and study the root of the medical philosophies and not just pick the flowers, and it’s from this same feeling that he encouraged his students to read the Yue Fu (乐府诗集) poetry of the Han and Wei dynasties and specifically the poet Wang Yuyang (王漁洋).

When the Japanese invaded the south, his hometown of Jiangyin, Jiangsu province fell into enemy hands and on December 7th, 1937, he died heroically resisting the invaders. While master Cao died a hero, the world lost a great Chinese medicine master. We are very fortunate to have several of his books available in order for subsequent generations to learn from not just in China, but also around the world. It is my hope in translating some of his cases that this knowledge can spread. We are also very fortunate to have scholar-physicians like my teacher Dr. Huang Huang uphold this love and dedication to master Cao’s work and to classical literature.

Case 1
Female. Since delivering a child her cycles come every forty days, which are accompanied by distending pain in the epigastrium following meals. When the cycle arrives, there is pain extending from the stomach to the lower abdomen. During the pain she experiences a strong desire to have a bowel movement. After the bowel movement the pain would typically stop. Pain would return the following afternoon and stop during the menstrual flow, and once again come and go the following day. Both pulses were wiry.
This is liver and gall-bladder exploiting deficiency of the spleen viscera. In this case Xiao Jian Zhong Tang with Chai hu and Huang Qin is appropriate.


Gui Zhi 3 qian
Sheng Bai Shao 5 qian
Zhi (Gan) Cao 2 qian
Sheng Jiang 5 pcs
Hong Zao 12 pieces
Yi Tang 2 liang
Chai Hu 3 qian
Jiu (Huang) Qin 1 qian
Tai Wu Yao 1.5 qian

After one package, her pain stopped and the menses ceased. Patient continued with two more packages, after which the condition resolved.
The master (Zhang Zhongjing) in his great classic said:


“In cold damage, (when) the yang pulse is choppy and the yin pulse is wiry, as a rule there should be urgent pain in the abdomen. First give Xiao Jian Zhong Tang; if it does not reduce, Xiao Chai Hu Tang governs.”
“伤寒,阳脉涩,阴脉弦,法当腹中急痛,先与小建中汤,不差者,小柴胡汤主之”.

Cao Yingfu (曹颖甫): Now here (in this case) I feel it goes without saying that there had not been a reduction and I immediately added Chai Hu and Huang Qin to treat her, why not? This woman’s situation was a menstrual disease and many belong to Chai Hu patterns, and so it was clearly obvious (to add it). The following day it was reported that the disease had resolved.

Case 2
Abdominal pain which liked pressure. During episodes of pain a distressing sensation of cold air was felt moving up and down (the body). Pulse was wiry-deficient. In addition there was an aversion to cold.
This is due to the liver exploiting the spleen and Xiao Jian Zhong Tang governs.
Gui Zhi 9g
Bai Shao 18g
Sheng Jiang 9g
Zhi Gan Cao 6g
Da Zao 6g
Yi Tang 30g

Liáo Shēng annotation: “This case is a pattern of abdominal pain (due to) central yang insufficiency with interior deficiency. The patient experienced abdominal pain, which liked pressure, the pulse was wiry-deficient and an aversion to cold was present. This signifies the overabundance of yin cold-qi, central yang insufficiency, and liver wood exploiting spleen (earth). Therefore Xiao Jian Zhong Tang was used to treat and resolve the condition.
The function of this formula is to supplement deficiency, quiet the center, moderate urgency and stop pain. The name of this formula is center fortifying (decoction). Fortify means to establish or set up, and because central qi is insufficient, it is very important to ‘establish’ or ‘set it up’. The formula contains sweat inducing (herbs) and not central effusing (herbs). It is referred to as a ‘minor’ (decoction) and only half (of the formula) resolves the exterior, so it does not completely secure the center. Xiao Jian Zhong Tang uses a heavy dose of Yi Tang, which is sweet, warm and serves as the sovereign to supplement the center. Bai Shao is the minister, which is sour and sweet to tonify yin. The assistant Gui Zhi is acrid-warm, which effuses and scatters. Combined with Bai Shao it regulates the nutritive and defense. In addition, Gan Cao, Da Zao and Sheng Jiang, which are sweet moderating and acrid warm, nourish the stomach and harmonize the center. Therefore (this formula) is able to warm and nourish central qi, calm and supplement yin and yang and regulate the nutritive and defense.”

*Xióng Liáo-Shēng (熊廖笙) style name Yǐ Xíng (以行) was born in 1905 in Ba County in Chongqing, Sichuan Province. Master Xióng was well versed in the classics, primarily the Nei Jing, Nan Jing, Shang Han Lun, and Jin Gui Yao Lue. The author of several books, Dr. Xióng possessed a deep and profound scholarship of the Shang Han Lun and was highly skilled in distilling the essence and precise details of various ancient doctors cases, which were found in his various annotations.

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Huáng Huáng’s Use of Guì Zhī Fú Líng Wán in Respiratory Conditions

Cinnamon Twig and Poria Pill (guì zhī fú líng wán)

Indications: Bronchial asthma, chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, pleurisy, pleural effusion, interstitial pneumonia, pulmonary fibrosis, and recurrent pulmonary infections typically manifesting with a dark-red complexion, a stifling sensation and pain in the chest, purple lips and a dark tongue. This formula has a blood invigorating, stasis transforming effect, which can improve the blood supply of the heart and lungs.

Usage & Modifications:

1. Patients for whom this formula is suitable tend to have a red or purple-red complexion, abdominal fullness, resistance to pressure in the lower left abdomen with possible tenderness, headaches, dizziness, insomnia, irritability, restlessness, stirring palpitations, and a dark tongue body with possible purple spots.

2. For patients that experience diarrhea after taking the formula, have them take in after meals or decrease the dosage.

3. Use with caution in pregnancy.

4. Modifications:

  • If there is a stifling sensation and pain in the chest, a chronic cough, and a wan and sallow complexion, add Angelicae sinensis Radix (dāng guī) 15g, Chuanxiong Rhizoma (chuān xiōng) 15g, and Salviae miltiorrhizae Radix (dān shēn) 15g
  • If there is a stifling sensation in the chest, abdominal distention, and an oily complexion, add Citri reticulatae Pericarpium (chén pí) 20g, Aurantii Fructus (zhǐ ké) 20g, and Zingiberis Rhizoma recens (shēng jiāng) 20g
  • If there is a stifling sensation in the chest  and constipation, add Aurantii Fructus (zhǐ ké) 20g, Allii macrostemi Bulbus (xiè bái) 20g, and Trichosanthis Fructus (quán guā lóu) 30g.

Representative Case History:

Yu, 74-year-old male, 160cm/70kg.

Initial consultation on June 5, 2018

Chief complaint: Recurrent cough and wheezing for 9 years, with dyspnea, an inability to climb stairs quickly, and abdominal distention following meals.

History: In April 2018 during a hospital visit, he was diagnosed with an acute exacerbation of chronic obstructive pulmonary disease (COPD), arrhythmia, atrial fibrillation, cardiac insufficiency, heart valve disease, and a fatty liver.

Signs: average build, dark, red and oily complexion, obvious bags under the eyes, purple-dark lips and tongue, stasis marks under the tongue, abdominal fullness, and resistance to pressure in the lower costal arch (flanks).

Prescription: Cinnamomi Ramulus (guì zhī) 10g, Cinnamomi Cortex (ròu guì) 10g, Poria (fú líng) 20g, Paeoniae Radix rubra (chì sháo) 20g, Moutan Cortex (mǔ dān pí) 15g, Persicae Semen (táo rén) 15g, Angelicae sinensis Radix (dāng guī) 15g, Chuanxiong Rhizoma (chuān xiōng) 15g, Salviae miltiorrhizae Radix (dān shēn) 15g, Aurantii Fructus (zhǐ ké) 30g, Citri reticulatae Pericarpium (chén pí) 30g, Zingiberis Rhizoma (gān jiāng) 10g; 15 packets.

Second consultation on June 25, 2018: After taking the herbs, his breathing was smooth and easy, however cough and wheezing were still present, but he was still able to play mah-jong. The same formula was continued.

Third consultation on August 20, 2018: No labored breathing when walking and he was able to climb 3 floors. The stasis marks under his tongue had improved.

Huáng Huáng – A Bàn Xià Hòu Pò Tāng Case

Huang, 65-year-old male, 171cm/75kg. 

Initial consultation on January 29, 2019.

History: Superficial gastritis with ulceration for over 10 years. Patient reported that he often experienced abdominal pain after taking western medications as well as abdominal discomfort after eating fruit. He felt a sticky sensation in his umbilicus, and also experienced abdominal distention, belching, poor appetite, difficulty falling asleep, and had no issues with his bowel movements. He was worried that his digestive disease will develop into cancer, and therefore, his mood was quite poor. 

Signs: Robust build, double eyelids, frowning eyebrows, lively facial expressions, a red face, and dusky red lips. In addition, he procrastinated when he spoke. His abdomen was soft, there were purple stasis marks below his tongue, his throat was red, tongue coating slightly greasy, and his pulse was slippery. 

Prescription: jiangbanxia 15g, houpo 15g, fuling 15g, sugeng 15g, zhike 15g, zhizi 15g, lianqiao 30g, huangqin 10g; 9 packets; 3 days on, 2 days off. 

Second consultation on February 26, 2019: After taking the formula, his symptoms had improved. However, once stopping them, the symptoms returned, yet this time there was no abdominal pain, and only a feeling of discomfort, plus the location of the pain had now changed. He was also belching, had subcostal distention, and his sleep was reduced. 9 packets of the same formula with chenpi 20g was given; 3 days on, 2 days off. 

Selected Clinical Case Histories of Liú Dù-Zhōu – Gé Gēn Tāng

 

Li X, a 38-year-old male. He had suffered with stubborn migraines for 2 years, which had not resolved despite being treated for a long time. He was introduced to Doctor Liu by a good friend and brought in for a consultation. 

Chief complaint: right sided headaches, which commonly extended to the forehead and supraorbital ridge. This was accompanied by an absence of sweating, chills, a runny nose with clear mucus, irritability, a red complexion, dizziness, and poor sleep. During examination, the patients’ range of motion in his back was inhibited, and on inquiry, the patient reported that his neck and occiput usually felt tight, more severely so during his headaches. His tongue was pale with a white coat, and his pulse was floating and slightly rapid. 

This was differentiated as cold pathogens being lodged in the taiyang channels, resulting in symptoms of inhibited flow of channel qi. 

Treatment required the promotion of sweat to expel pathogens, and unblock taiyang qi, so Kudzu Decoction (gé gēn tāng) was given: 

Ephedrae Herba (má huáng) 4g
Puerariae Radix (gé gēn) 18g
Cinnamomi Ramulus (guì zhī) 12g
Paeoniae Radix alba (bái sháo) 12g
Glycyrrhizae Radix praeparata (zhì gān cǎo) 6g
Zingiberis Rhizoma recens (shēng jiāng) 12g
Jujubae Fructus (dà zǎo) 12 pieces

Ephedrae Herba (má huáng) and Puerariae Radix (gé gēn) were to be decocted first with the froth removed before adding the other ingredients. 

After taking the decoction, the patient was covered up so a slight sweat could be obtained. He was instructed to avoid cold drafts. 

After taking 3 packets, his back felt warm, which was followed by a mild sweat throughout the body, and a reduction in his headache and neck tension. 15 packets of the same formula was
prescribed again, which completely resolved his headaches and neck tension. 

Selected Clinical Case Histories of Liu Du-Zhou (Liú Dù-Zhōu lín zhèng yàn àn jīng xuǎn)

The Classic Formulas (Jīng Fāng) System of Treatment Based on Pattern Identification By Féng Shì Lún

 
 
1.     What is Treatment Based on Pattern Identification
Pattern identification is a method in which (one) gathers disease responses and symptoms through the four diagnostic methods, and also uses Chinese medical theory to summarize and analyze (these responses) in order to distinguish the disease nature and location (and to have) a clear understanding of the disease signs. This is another step in elucidating the pattern involved, and this process is referred to as pattern identification. Determining treatment is essentially the use of medicinals in accordance with the pattern. The characteristic (of this process) is that both the patient and the doctor work together in gathering the symptoms (to obtain information), and the doctor, in accordance with Chinese medical theory, will summarize and analyze (these) to have a clear understanding of where these signs belong (information classification), in order to clearly define the pattern (treating the specific information), and use medicinals according to the pattern (information processing). This is the entire process involved in treating disease.
The pattern identification methods commonly used in Chinese medicine are: eight principles pattern identification, bowel and viscera pattern identification, qì, blood, liquids, and humors pattern identification, defensive qì and nutritive blood pattern identification, triple warmer pattern identification, channels and collaterals pattern identification, six conformation pattern identification, and so on. The Shāng hán lùn (傷寒論 Discussion of Cold Damage) specifically uses the six conformations pattern identification method.
2.    The Evolution of the Shāng hán lùn’s Treatment Based on Pattern Identification
Treatment based on pattern identification is also referred to as treatment based on pattern differentiation. The Chinese medicine use of formulas and medicinals to treat disease is a particularly traditional method, which has been put into practice for extensive periods of time by our ancestors through the ages to combat disease, and is summed up as a major extraordinary accomplishment. The earliest recording, which established and summarized these methods is found in the Decoction classic ().
  
3.     Discussion on the Six Conformations and Eight Principles
The Shāng hán lùn (傷寒論 Discussion of Cold Damage) used the six conformations as a method of division. Later commentators have stated that with the six conformations, one would only be confined to cold damage methods. In fact, the six conformations come from the eight principles (and are the) general principles behind (the treatment) of numerous diseases. In order to explain further, the following discussion will begin from the eight principles.
(1) Eight Principles [ ]
The eight principles refer to the exterior, interior, yīn, yáng, cold, heat, vacuity, and repletion. In actual fact, within the exterior and interior, there is also the half-exterior and half-interior, so really, they should be called the nine principles. However, the half-exterior, half-interior portion is usually discussed with the interior, so it is customary to simply refer to them as the eight principles.  I will now explain them in order.
The Exterior, Interior, and Half-Exterior Half-Interior: 
The exterior, interior, and half-exterior half-interior are essentially the location of a disease response.  The exterior refers to the exterior of the body, namely the skin, muscles, flesh, tendons, and bones, and anything, which constitutes the outer part of the body can be called the exterior.  If pathogenic factors accumulate and cause a reaction in this part of the body, we can call this an exterior pattern.  The interior refers to the inner aspect of the body, namely the esophagus, stomach, large intestine, and small intestine, and anything, which constitutes the digestive tract, is referred to as the interior. If pathogenic factors accumulate and elicit a response in this part of the body, this can be called an interior pattern.  The half-exterior half-interior portion refers to the exterior of the interior, and the interior of the exterior, which is namely the large space between the chest and abdomen. This is the location of all the organs and bowels, and is considered to be the half-exterior half-interior portion of the body. If pathogenic factors accumulate here and cause a reaction, this is called a half-exterior half-interior pattern.  It needs to be explained here that the exterior, interior, and half-exterior half-interior disease location responses are fixed, and regardless of what the disease is, (one needs to look at) the location of the disease response, whether it be in the exterior, interior, or half-exterior half-interior. In addition, two or even all three of these may sometimes appear simultaneously. It must also be emphasized that here when discussing disease location, it refers to the location of the response to the disease pathogens, and not to be mistakenly believed to be the location of the disease changes. That is to say, if there are pathological changes in the interior, but pathogenic factors have accumulated and caused a response in the exterior, this is referred to as an exterior pattern, and is also referred to as pathogens in the exterior or an exterior disease. For the same reason, even if a condition manifests with exterior symptoms, yet there is an accumulation of pathogenic factors with a response in the interior of the body, this is referred to as an interior pattern, for which it can also be said that pathogens are in the interior, or simply called an interior disease.
Yīn and Yáng: Yīn and Yáng refer to the nature of the pathological changes. Yīn has namely a yīn nature, and yáng a yáng nature. When a person contracts a disease, there will be a struggle between right (qì) and the pathogen. This will have not yet influenced any changes of bodily functions, and will particularly first make changes to metabolic functions. If this change is relatively abnormal, than it is called excessive, and if relatively normal, it is considered deficient. With excess, the body will correspond with and reflect hyperactivity, rising, and excited types of disease characteristics, which are referred to as a yáng pattern. With deficiency, the body will reflect decline, hypo-function, and inhibition types of deficient disease characteristics, which are referred to as a yīn pattern. 
Cold and Heat: 
Cold refers to a cold type of pattern, while heat refers to a hot type of pattern. If a patient reflects cold natured symptoms, then this is ultimately considered a cold pattern; if a patient reflects heat type symptoms, then this is referred to as a heat pattern. As was mentioned above in the explanation of yīn and yáng, cold is a reflection of deficiency, which belongs to yīn, therefore cold is also yīn, and heat is a reflection of excess, which belongs to yáng, so therefore heat must also be yáng.  However, cold and heat have characteristics of yīn and yáng, and if we generally say yīn, then indefinitely there must be cold, and if we say yáng, then there will indefinitely be heat. In instances of an absence of cold or heat in disease, this by no means indicates an absence of yīn or yáng.)
Vacuity and Repletion: 
Vacuity refers to a vacuous patient, while repletion refers to repletion of disease (factors). If a disease has not yet been resolved, and a patients’ energy is failing to sustain to some extent, the reflection of the body manifests a type of vacuous, debilitated state, which is typically referred to as a vacuity pattern. If the dynamics of the disease are advanced, and the patients’ energy is not vacuous, the body will manifest with disease characteristics of fullness and repletion, which would be referred to as a repletion pattern. From the aforementioned explanation, we are able to see that vacuity, repletion, cold and heat are similar, containing both yīn and yáng characteristics within them. When vacuity, repletion and cold intertwine with one another, there is still (either) yīn or yáng. For example, vacuity and cold are definitely yīn, but vacuity and heat is on the contrary yáng. Repletion and heat are most certainly yáng, however, repletion and cold would be considered yīn. In a yáng pattern it is possible to have heat, or repletion, or heat with repletion, no heat or no repletion, or even heat and vacuity. In a yīn pattern, we can have either cold, or vacuity, or vacuity with cold, no cold or no vacuity, or cold with repletion. This can be seen in the following chart.
 
 
(1) Six Conformations ()
The six conformations refers to the three yáng conformations of Tài Yáng, Yáng Míng, and Shào Yáng, and the three yīn conformations of Tài Yīn, Shào Yīn, and Jué Yīn. Although the Shāng hán lùn (傷寒論 Discussion of Cold Damage) refers to these as diseases, they are actually patterns, which come from the eight principles. I will now explain the relationships between them.
The so-called exterior, interior, and half exterior half interior, all reflect disease location, while yīn, yáng, cold, heat, vacuity, and repletion reflect the nature of the disease.  However, the manifestation of the disease nature must reflect the disease location, and the location of the disease will inevitably reflect the nature of the disease, therefore, without the nature of the disease, there is no location, and vice versa. Exterior, interior, or half exterior half interior patterns will always be accompanied by signs of either yīn, yáng, cold, heat, vacuity or repletion.  At the same time, yīn, yáng, cold, heat, vacuity, and repletion patterns will be accompanied by exterior, interior, or half exterior half interior signs. Therefore, regardless of whether it’s an exterior, interior, or a half exterior half interior pattern they will all be accompanied by various yīn and yáng signs and responses.  
Disease location and nature of the six conformations
Eight Principles
Disease nature
Six conformations
Disease location
Exterior
Yáng
Tài Yáng disease
Interior
Yáng
Yáng Míng disease
Half exterior half interior
Yáng
Shào Yáng disease
Interior
Yīn
Tài Yīn disease
Exterior
Yīn
Shào Yīn disease
Half exterior half interior
Yīn
Jué Yīn disease
The following are the representative lines from the Shāng hán lùn (傷寒論 Discussion of Cold Damage) for each of the six conformations with a small commentary.
“In Tài Yáng disease, the pulse is floating, the head and nape are stiff and painful, and there is aversion to cold” [line 1]
Commentary: Tài Yáng disease is an exterior yáng pattern. The characteristics signs of a Tài Yáng disease are a floating pulse, stiff and painful head and nape, and aversion to cold. With that being said, in any disease, whenever a floating pulse, a stiff and painful head and nape, and aversion to cold are seen, one can most certainly diagnose it as a Tài Yáng disease, thereby avoiding any errors.
“In Yáng Míng disease, the stomach domain is replete” [line 180]
Commentary:  Yáng Míng disease is an interior yáng pattern. The term ‘stomach domain is replete’ means that pathogens are full and replete in the stomach and intestines, and with palpation is hard with resistance and possibly painful on pressure. The general idea here is that any disease with a replete stomach domain, can definitely be considered a Yáng Míng disease.
“What are the external signs of Yáng Míng disease? Answer: generalized heat effusion, spontaneous sweating, and no aversion to cold, but aversion to heat” [line 182]
Commentary: The stomach domain being replete, is a Yáng Míng disease abdominal finding, and in addition there is also a Yáng Míng disease exterior pattern. Symptoms of generalized heat effusion, spontaneous sweating, and no aversion to cold, but aversion to heat exemplify the exterior pattern.  Any disease with these external signs can be diagnosed as a Yáng Míng disease.
“In Shào Yáng disease, there is a bitter taste in the mouth, dry throat, and dizzy vision” [line 263]
Commentary: Shào Yáng disease is a half exterior half interior yáng pattern. The characteristic symptoms for a Shào Yáng pattern are a bitter taste in the mouth, dry throat, and dizzy vision. Any disease with these characteristic signs could be diagnosed as a Shào Yáng disease.
 
“In Tài Yīn disease, there is abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. If purgation is used, there will be a hard bind below the chest” [line 273]
Commentary: Tài Yīn disease is an interior yīn disease. The characteristic symptoms of a Tài Yīn disease are abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain. Any disease manifesting these characteristics can be diagnosed as a Tài Yīn disease. The abdominal fullness in a Tài Yīn disease is a vacuity type of fullness, which is quite different than the repletion fullness seen in a Yáng Míng repletion of the stomach domain disease. If one erroneously mistakes this for a repletion type of fullness and purges it, this will further increase the vacuity and cause a hard bind below the chest.
“In Shào Yīn disease, the pulse is faint and fine, and there is a desire only to sleep” [line 281]
Commentary: Shào Yīn disease is an exterior yīn pattern, which needs to be compared to a Tài Yáng pattern. Basically, if there is a Tài Yáng pattern with a faint and fine pulse, accompanied by a desire only to sleep, this can be diagnosed as a Shào Yīn disease.
Commentary: Jué Yīn disease is a half exterior half interior yīn disease. The symptoms which typically reflect a Jué Yīn disease are wasting thirst, qi surging upward to the heart, pain and heat in the heart, hunger with no desire to eat, and vomiting of roundworms after eating. Any disease seen with these symptoms can be considered a Jué Yīn disease. Half exterior half interior pattern cannot be purged, and it is especially strictly prohibited when they are yīn patterns. If one is not careful and erroneously uses purgation, then this will cause a calamity of incessant diarrhea.
1.     Summary of Treatment Principles
The so-called treatment principles are essentially the principle of determination of treatment based on six conformation and eight principles pattern identification.  I will now differentiate and give an account of these principles.
Tài Yáng disease: Because this is an exterior pattern, it is appropriate to effuse sweat, and not to purge nor cause vomiting. Formulas such as guì zhī tāng (Cinnamon Twig Decoction), má huáng tāng (Ephedra Decoction), and gé gēn tāng (Kudzu Decoction) are specific sweat effusing Tài Yáng disease formulas.
Shào Yīn disease: This is a type of Tài Yáng disease, and although they both belong to the exterior, for which sweating should resolve it, here sweat effusion must be combined with warm natured, stimulating medicinals such as fù zǐ (Aconiti Radix lateralis preparata), and xì xǐn (Asari Herba) in formulas such as guì zhī jiā fù zî tāng (Cinnamon Twig Decoction plus Aconite), má huáng fù zǐ gān cǎo tāng (Ephedra, Aconite Accessory Root Tuber and Licorice Decoction), and má huáng fù zǐ xì xīn tāng (Ephedra, Aconite Accessory Root Tuber and Asarum Decoction). These are specific Shào Yīn sweat effusing formulas.
Yáng Míng disease: When heat has bound in the interior and the stomach domain is replete, it is appropriate to purge it. However, when there is (simply) heat and no repletion (in the stomach domain), it is appropriate to simply clear heat. A typical purging formula would be one of the chéng qì tāng (Order the Qi Decoction) formulas, and bái hǔ tāng (White Tiger Decoction) to clear heat. If there is repletion in the chest, it is appropriate here to cause vomiting and not to purge using a formula such as guā dì sǎn (Melon Stalk Powder).
Tài Yīn disease: With interior vacuity and cold obstruction, only warming and supplementation is warranted. The promotion of sweat, vomiting and purgation are all contraindicated. Formulas such as lǐ zhōng tāng (Regulate the Middle Decoction), and sì nì tāng (Frigid Extremities Decoction) are typical Tài Yīn warming and supplementing formulas.
Shào Yáng disease: In half exterior half interior patterns, the appropriate method of treatment is to harmonize and resolve. Promoting sweating, vomiting and purgation are all unnecessary. xiǎo chái hú tāng (Minor Bupleurum Decoction) and huáng qín tāng (Scutellariae Decoction) are prototypical Shào Yáng harmonizing and heat resolving formulas.
Jué Yīn disease: Although this is also a half exterior half interior pattern, for which harmonizing and resolving are appropriate, this must be combined with warm, strengthening medicinals. Chái hú guì zhī gān jiāng tāng (Bupleurum, Cinnamon Twig, and Ginger Decoction) and wū méi wán (Mume Pill) are typical formulas for this pattern.
Cold and Heat: In cold patterns, warming medicinals should be used to expel cold such as gān jiāng (Zingiberis Rhizoma), fù zǐ (Aconiti Radix lateralis preparata), and wū tóu (Aconiti Kusnezoffi Radix) in combination with specific formulas. In heat patterns, cool and cold medicinals are used in order to eliminate heat such as huáng qín (Scutellariae Radix), zhī zǐ (Gardeniae Fructus), huáng lián (Coptidis Rhizoma), and shí gāo (Gypsum fibrosum) in combination with specific formulas.
Vacuity and Repletion: In vacuity patterns it is appropriate to use strengthening medicinals in order to supplement insufficiency. Sweat promoting, vomiting, and purgative medicinals are all contraindicated. Formulas such as zhì gān cǎo tāng (Honey-Fried Licorice Decoction), lǐ zhōng tāng (Regulate the Middle Decoction), and shèn qì wán (Kidney Qì Pill) are all used to supplement vacuity. In repletion patterns, sweat promoting, vomiting inducing, and purgation are all methods, which are utilized to thoroughly attack and eliminate pathogenic factors. Examples of attacking repletion formulas would be má huáng tāng (Ephedra Decoction) and dà chéng qì tāng (Major Order the Qi Decoction).
Case Example:
 
Guì Zhī Jiā Gé Gēn Tāng (Cinnamon Twig Decoction plus Kudzu)
On December 10, 1965 a twenty one-year-old female presented at the clinic. Yesterday she had contracted a common cold manifesting with symptoms of headache, dizziness, sweating, aversion to cold, weak pain in her shoulders and back, and a tight obstructive pain in the left side of her neck on rotation towards the left. She had a thin white tongue coating, and her pulse was floating and slightly rapid.
A floating, slightly rapid pulse, thin-white tongue coat, aversion to cold, sweating, and headaches signify a Tài Yáng wind strike pattern. Shoulder and back pain, and neck pain on left rotation of the head signify a gé gēn tāng (Kudzu Decoction) pattern. The dizziness indicates that the exterior has not yet been resolved, with upward surging of qì.
Comprehensive analysis: This is a Tài Yáng wind strike pattern with simultaneous stretched stiff nape and back, seen in a guì zhī jiā gé gēn tāng (Cinnamon Twig Decoction plus Kudzu) formula presentation.
Formula:
guì zhī (Cinnamomi Ramulus) 10g
bái sháo (Paeoniae Radix alba) 10g
shēng jiāng (Zingiberis Rhizoma recens) 10g
dà zǎo (Jujubae Fructus) 4 pieces
zhì gān cǎo (Glycyrrhizae Radix preparata) 6g
gé gēn (Kudzu Radix) 12g
Results:  After taking 1 package of the formula, her symptoms decreased, and after 2 more, her symptoms had completely resolved.
 

Dr. Féng Shì-Lún on Tài Yīn Presentations

Classical Formulas Interior Yīn Presentations (Tài Yīn disease)%E5%86%AF%E4%B8%96%E7%BA%B6.jpg

  1. The Concept of Interior Yīn Presentations

Clause 273 in the Shāng hán lùn (傷寒論 Discussion of Cold Damage) says:

“In Tài Yīn disease, there is abdominal fullness and vomiting, inability to get food down, severe spontaneous diarrhea, and periodic spontaneous abdominal pain, and if purgation is used, there will be a hard bind below the chest”.

This is the essential outline of a Tài Yīn and interior yīn presentation, which is describing an interior vacuity with accumulation of rheum, therefore manifesting with abdominal fullness and vomiting, and an inability to get food down, not only because there is cold rheum in the stomach, but also because (the stomach) is unable to receive it, thus also manifesting with severe spontaneous diarrhea.  (When) cold qì descends into the lower abdomen there will be spontaneous abdominal pain, and when cold does not descend, pain will spontaneously cease. Tài Yīn disease should be treated with warmth, and not with purgation. If one fails to heed to these words and erroneously purges, this will increase the vacuity of the stomach and the rheum accumulation, which will result in the transformation of cold, manifesting with a hard bind below the chest. This is the general characteristics of a Tài Yīn disease, and any disease manifesting with these signs, can be deemed a Tài Yīn disease, and if (one) uses the methods of treatment for a Tài Yīn disease, all errors would be avoided.

  1. Treatment Principles for Interior Yīn Presentations

Clause 277 of the Shāng hán lùn (傷寒論 Discussion of Cold Damage) says:

“When there is spontaneous diarrhea and an absence of thirst, this belongs to Tài Yīn disease; because there is cold in the viscera, a warming treatment should be used, and a Sì Nì type (of formula) is suitable”.

Not only is this line expounding on the characteristics of a Tài Yīn disease, but also mentions its treatment principle. It is saying that all diseases manifesting with spontaneous diarrhea with an absence of thirst, belong to Tài Yīn disease. Here, there is no thirst due to cold rheum in the stomach, and in order to treat it, a sì nì type of formula is suitable to warm the center and expel cold. In short, both Yáng Míng and Tài Yīn diseases are located in the interior, with the former being a yáng presentation and the latter a yīn presentation.  Interior yáng Yáng Míng presentations manifest with copious heat and excess, while interior yīn Tài Yīn presentations manifest as cold and vacuity. Diarrhea can occur in both Yáng Míng and Tài Yīn diseases, however, with heat there is thirst, and with cold there is an absence of thirst. This is the key in differentiating these two patterns.  Sì Nì types of formulas warm the center, and expel cold, and not only do they treat Tài Yīn disease diarrhea, but they are also the standard formulas for addressing Tài Yīn diseases in general.

  1. The Major Formula Presentations in Interior Yīn patterns

In the Shāng hán lùn (傷寒論 Discussion of Cold Damage), it is said that in order to treat Tài Yīn disease, a warming strategy is appropriate, and a sì nì type of formula should be used.  However, there is not one specific formula for the multitude of presentations, and according to the concept of  “cold in the viscera” the following are the formulas used to address these patterns.

(i) Gān Jiāng Fù Zǐ Tāng (Dried Ginger and Aconite Accessory Root Decoction) Category of Formulas:

Gān Jiāng Fù Zǐ Tāng (Dried Ginger and Aconite Accessory Root Decoction):

gān jiāng (Zingiberis Rhizoma) 3 liǎng

fù zǐ (Aconiti Radix lateralis preparata) (used fresh) 3 liǎng

Cooking method: Use three glasses of water, boiling until reduced to one cup, and take warm.

Indications: Both gān jiāng (Zingiberis Rhizoma) and fù zǐ (Aconiti Radix lateralis preparata) are center warming, cold expelling medicinals. However, gān jiāng is mainly used to treat ascending counterflow of cold rheum, while fù zǐ is used to address cold rheum distressing the lower body. Combining these two medicinals to warm the upper and lower, creates a strong formula that will invariably warm the center and expel cold. It is used to treat cold extremities, generalized body coldness, and a deep-faint pulse.

Other similar formula presentations:

Sì Nì Tāng (Frigid Extremities Decoction):

zhì gān cǎo (Glycyrrhizae Radix preparata) 2 liǎng

gān jiāng (Zingiberis Rhizoma) 1 ½ liǎng

fù zǐ (Aconiti Radix lateralis preparata) (fresh) 1 piece

There are over ten detailed clauses in the Shāng hán lùn (傷寒論 Discussion of Cold Damage) describing the use of this formula, however, the main presentation of this formula is severe interior cold vacuity manifesting with cold extremities and a faint pulse verging on expiry.

Tōng Mài Sì Nì Tāng (Vessel Freeing Frigid Extremities Decoction):

This formula is sì nì tāng with increased dosages of gān jiāng and fù zǐ. It is used for a sì nì tāng presentation with more extreme vacuity cold.

Tōng Mài Sì Nì Jiā Zhū Dǎn Zhī Tāng (Vessel Freeing Frigid Extremities Decoction Plus Pig’s Bile:

This formula is tōng mài sì nì tāng with the addition of zhū dǎn zhī (pig’s bile). It is indicated for a more severe tōng mài sì nì tāng presentation with a faint pulse verging on expiry, or an imperceptible pulse.

Sì Nì Jiā Rén Shēn Tāng (Frigid Extremities Decoction plus Ginseng):

This is sì nì tāng with rén shēn (Ginseng Radix). It is indicated in cases of stomach qì vacuity with a weak pulse following vomiting or purgation.

Fú Líng Sì Nì Tāng (Poria Frigid Extremities Decoction):

This formula is sì nì jiā rén shēn tāng with fú líng (Poria). It is typically used in a sì nì jiā rén shēn tāng presentation with additional signs of palpitations below the heart, vexation, agitation, and inhibited urination.

(ii) Fù Zǐ Tāng (Aconiti Radix lateralis preparata Decoction) Category of Formulas:

Fù Zǐ Tāng (Aconiti Radix lateralis preparata Decoction):

fù zǐ (Aconiti Radix lateralis preparata) [blast fried] 1 piece

fú líng (Poria) 3 liǎng

rén shēn (Ginseng Radix) 2 liǎng

bái zhú (Atractylodis macrocephalae Rhizoma) 4 liǎng

sháo yào (Paeoniae Radix) 3 liǎng

Indications: stomach vacuity with cold rheum manifesting with inhibited urination, generalized body pain, joint pain, and possible abdominal cramping pain.

Other similar formula presentations:

Zhēn Wǔ Tāng (True Warrior Decoction):

This formula is fù zǐ tāng with the rén shēn removed, and the addition of shēng jiāng. It is used for a fù zǐ tāng presentation with dizziness, palpitations, edema in the lower extremities, and possible pain.

Fù Zǐ Jīng Mǐ Tāng (Aconite Root And Glutinous Rice Decoction):

fù zǐ (Aconiti Radix lateralis preparata) [blast fried] 1 piece

jīng mǐ (Glutinous Rice) ½ shēng

bàn xià (Pinelliae Rhizoma preparatum) ½ shēng

zhì gān cǎo (Glycyrrhizae Radix preparata) 1 liǎng

dà zǎo (Jujubae Fructus) 10 pieces

This formula is indicated for patterns of interior vacuity cold with abdominal pain, intestinal noise, nausea, and retching counterflow.

Chí Wán (Red Pill):

fú líng (Poria) 4 liǎng

bàn xià (Pinelliae Rhizoma preparatum) 4 liǎng

wū tóu (Aconiti Radix) [blast fried] 1 piece

xì xǐn (Asari Herba) 1 liǎng

This is indicated for cold natured abdominal pain accompanied by counterflow qì.

Dà Wū Tóu Jiān (Major Aconite Main Tuber Brew):

This formula is simply 5 large pieces of wū tóu (skin removed) boiled with honey added afterwards. It is used for cold mounting abdominal pain, reversal counterflow in the four extremities, and a deep, wiry pulse.

(iii) Gān Cǎo Gān Jiāng Tāng (Licorice and Ginger Decoction) Category of Formulas:

Gān Cǎo Gān Jiāng Tāng (Licorice and Ginger Decoction):

zhì gān cǎo (Glycyrrhizae Radix preparata) 6 liǎng

gān jiāng (Zingiberis Rhizoma) 3 liǎng

Indications:  Stomach vacuity cold with ejection of foamy drool and vomiting counterflow.

Other similar formula presentations:

Lǐ Zhōng Tāng or Wán (Regulate the Middle Decoction or Pill):

This formula is gān cǎo gān jiāng tāng with the addition of rén shēn and bái zhú. It treats a gān cǎo gān jiāng tāng presentation with hard epigastric glomus and inhibited urination.

Dà Jiàn Zhōng Tāng (Major Construct the Middle Decoction):

shǔ jiāo (Zanthoxyli Pericarpium) 3 liǎng

gān jiāng (Zingiberis Rhizoma) 6 liǎng

rén shēn (Ginseng Radix) 3 liǎng

jiāo yí (Malt Sugar) 1 shēng

This formula is indicated for stomach vacuity cold patterns manifesting with severe chest and abdominal pain, vomiting counterflow, and an inability to eat.

(iv.) Jú Pí Tāng (Tangerine Peel Decoction) Category of Formulas:

Jú Pí Tāng (Tangerine Peel Decoction):

jú pí (Citri Reticulatae Pericarpium) 4 liǎng

shēng jiāng (Zingiberis Rhizoma recens) 8 liǎng

Indications: Dry retching and poor food intake.

Other similar formula presentations:

Jú Pí Zhǐ Shí Shēng Jiāng Tāng (Tangerine Peel, Unripe Bitter Orange, and Fresh Ginger Decoction):

This formula is jú pí tāng with a higher dose of jú pí and distention clearing, bind breaking zhǐ shí added. It treats a jú pí tāng presentation with more severe counterflow fullness and glomus and congestion in the chest.

Jú Pí Zhú Rú Tāng (Tangerine Peel and Bamboo Shavings Decoction):

This formula is jú pí tāng with a double dose of jú pí and the additions of zhú rú (Bambusae Caulis in Taenia) to treat coughing and counterflow ascent of qì and gān cǎo, rén shēn, and dà zǎo to calm the center and relax tension. It is used to treat a jú pí tāng presentation with stomach vacuity hiccups, retching, cough and counterflow.

Fú Líng Yǐn (Poria Beverage):

This formula is jú pí zhǐ shí shēng jiāng tāng with the addition of rén shēn to strengthen the stomach, and fú líng to disinhibit water. It is indicated for patterns manifesting with epigastric distention and fullness, epigastric glomus, poor food intake, shortness of breath, and inhibited urination.

(v) Bàn Xià Tāng (Pinellia Decoction) Category of Formulas:

Bàn Xià Tāng (Pinellia Decoction):

bàn xià (Pinelliae Rhizoma preparatum) 1 shēng

shēng jiāng (Zingiberis Rhizoma recens) ½ jīn

Indications: water rheum in the stomach with vomiting counterflow and possible headaches and a lack of thirst.

Other similar formula presentations:

Shēng Jiāng Bàn Xià Tāng (Fresh Ginger and Pinellia Decoction):

This formula is xiǎo bàn xià tāng with an increased dosage of shēng jiāng. It treats a bàn xià Tāng presentation with more severe rheum.

Xiǎo Bàn Xià Jiā Fú Líng Tāng (Minor Pinellia Decoction Plus Poria):

This is xiǎo bàn xià tāng with the addition of fú líng, and treats a similar presentation with the additional signs of heart palpitations and dizziness.

Bàn Xià Gān Jiāng Sǎn (Pinellia and Dried Ginger Powder):

This is xiǎo bàn xià tāng with gān jiāng used instead of shēng jiāng.  It treats dry retching, and ejection of foamy drool due to stomach vacuity cold.

Dà Bàn Xià Tāng (Major Pinellia Decoction):

This formula is composed of:

bàn xià (Pinelliae Rhizoma preparatum) 2 shēng (washed)

rén shēn (Ginseng Radix) 3 liǎng

bái mì (honey) 1 shēng

It is used in stomach vacuity cold patterns with epigastric glomus and vomiting.

Gān Jiāng Bàn Xià Rén Shēn Wán (Dried Ginger, Pinellia, and Ginseng Pill):

This formula is a combination of xiǎo bàn xià tāng and bàn xià gān jiāng sǎn, and is used to treat more sever vomiting, and a hard epigastric glomus. The pill form of this medicine is milder, but is safer to use when treating morning sickness in pregnant patients.

Hòu Jiāng Bàn Gān Shēn Tāng (Officinal Magnolia Bark, Fresh Ginger, Pinellia, Licorice, and Ginseng Decoction):

This formula is shēng jiāng bàn xià tāng with a high dose of hòu pò to eliminate distention and fullness, and the additions of rén shēn and gān cǎo to supplement the center; therefore, it treats a shēng jiāng bàn xià tāng presentation with abdominal fullness and distention.

Bàn Xià Hòu Pò Tāng (Pinellia and Magnolia Bark Decoction):

This formula is xiǎo bàn xià jiā fú líng tāng with the addition of hòu pò and sū yè (zǐ). It treats phlegm-rheum qì bind causing chest fullness, throat blockage, coughing and counterflow.

Xuán Fù Dài Zhě Tāng (Inula and Hematite Decoction):

This formula is hòu jiāng bàn gān shēn tāng with hòu pò removed and xuán fù huā, dài zhě shí, and dà zǎo added.  It is indicated in patterns of stomach vacuity cold with vomiting counterflow.

(vi) Zhū Líng Sǎn (Polyporus Powder) Category of Formulas:

Zhū Líng Sǎn (Polyporus Powder):

This formula is composed of equal parts zhū líng, fú líng, and bái zhú. It treats stoppage and depression of fluids in the stomach transforming into heat with symptoms of vomiting, thirst, and inhibited urination.

Other similar formula presentations:

Zé Xiè Tāng (Alismatis Decoction):

This formula is zhū líng sǎn, with both zhū líng and fú líng removed, and zé xiè added. It treats water rheum in the stomach with inhibited urination and dizziness.

Fú Líng Zé Xiè Tāng (Poria and Alismatis Decoction):

This is líng guì zhú gān tāng with the addition of zé xiè and shēng jiāng, and treats vomiting, inhibited urination, and thirst with a desire to drink water.

Gān Cǎo Gān Jiāng Fú Líng Bái Zhú Tāng (Licorice, Dried Ginger, Poria, and Atractylodes Decoction):

This is gān cǎo gān jiāng tāng with the addition of fú líng and bái zhú. It treats lumbar cold and heaviness, and spontaneously uninhibited urination.

The above-mentioned formulas all treat Tài Yīn disease interior vacuity cold presentations. Tài Yīn disease is an interior yīn pattern, where pathogens have entered the interior, which will present with interior yīn signs. When a persons’ right qì is insufficient, and the right and pathogens contend with each other in the interior for an extended period of time, this can result in a whole host of transmuted patterns.

When interior vacuity cold is affected by blood vacuity or vacuity of fluids, blood nourishing or fluid generating formulas should be used, such as, xiōng guī jiāo ài tāng (Chuanxiong, Chinese Angelica, Ass Hide Glue, and Mugwort Decoction), dāng guī sháo yào sǎn (Tangkuei and Peony Powder), wēn jīng tāng (Channel-Warming Decoction), zhì gān cǎo tāng (Honey-Fried Licorice Decoction), huáng tǔ tāng (Yellow Earth Decoction), bā wèi wán (Eight-Ingredients Deoction), etc. In addition, when disease pathogens are in the interior and the condition responds differently, we must select different formulas with specific indications to address these changes, such as guā lóu xiè bái bàn xià tāng (Trichosanthes, Long Stamen Onion, and Pinellia Decoction), yì yǐ fù zǐ bài jiàng sǎn (Coix, Aconite, and Patrinia Powder), and several others.  Zhòng Jǐng discussed these fine details quite meticulously, and when we carefully consult his works, we can achieve positive (clinical) results.

  1. The Position of Tài Yīn Disease Amongst The Six Channels

In regards to classical formulas, generally speaking, when pathogens are in the exterior, the disease is easy to resolve and the disease nature is quite mild.  If pathogens are located in the interior, then the disease is difficult to cure, and the nature is more serious. This can be seen clearly from the analysis of formula presentations. With an interior disease, regardless if it is a yáng presentation or a yīn presentation, they are all more serious patterns.  For example, in an interior yáng Yáng Míng presentation, we see; “late afternoon tidal heat effusion, no aversion to cold and soliloquy as if the person is seeing ghosts, and if serious the person will not recognize people, will pick at the bedclothes, feel fear and disquietude, pant slightly and stare forward”.  “Delirious speech and tidal heat” is a dà chéng qì tāng (Major Order the Qi Decoction) presentation; Another example is; “abdominal fullness, generalized heaviness, difficulty turning sides, insensitivity of the mouth, grimy face, delirious speech, and enuresis. If sweating is promoted, there will be delirious speech, and if purgation is used, sweat will arise on the forehead, and there will be reversal cold of the extremities”.  This is a bái hǔ tāng (White Tiger Decoction) presentation.

These are all interior yáng presentations, which are quite serious and have already affected the mind. These are the interior signs that appear when right qi is still vigorous and can resist pathogenic qì, and if it becomes too weak, it must be treated otherwise it would threaten (one’s life). With interior yīn presentations, right qi is originally vacuous, and when pathogens are exuberant in the interior, right qì is unable to overcome these pathogens and they become dangerous in a very short time. By looking at the yáng returning and counterflow stemming effect of the sì nì formulas, this concept becomes quite clear. For example, clause 388 says:

“When there is vomiting and diarrhea, sweating, heat effusion, and aversion to cold, hypertonicity of the limbs, and reversal cold of the extremities, sn sì nì tāng (Frigid Extremities Decoction governs”.

Clause 389 says:

“When there is vomiting as well as diarrhea, then uninhibited urination, and great sweating, clear food diarrhea, internal cold and external heat, and the pulse is faint and verging on expiry, sì nì tāng (Frigid Extremities Decoction) governs”.

Clause 390 says:

When the vomiting has ceased and the diarrhea has stopped, yet there is sweating and reversal, unresolved hypertonicity of the limbs, and a pulse that is faint and verging on expiry, tōng mài sì nì jiā zhū dǎn zhī tāng (Vessel Freeing Frigid Extremities Decoction Plus Pig’s Bile governs”.

Clause 309 says:

“When in Shào Yīn disease there is vomiting and diarrhea, counterflow cold of the extremities, and vexation and agitation, as if the person is about to die, wú zhū yú tāng (Evodia Decoction) governs”.

In all these presentations, the bodies right qì and yáng qì are both vacuous, and pathogenic qì is strong and exuberant in the interior, already posing a risk and threatening life. One cannot hesitate with treatment, and for there to be a gleam of hope in survival, a major formula to return yáng and stem counterflow must be used.  Now, of course in clinical practice, not all Tài Yīn cases are this critical and severe, but most are chronic conditions, which are basically interior vacuity cold patterns, as seen with the xiǎo bàn xià tāng, dà bàn xià tāng, xuán fù dài zhě tāng, fú líng yǐn, wú zhū yú tāng, lǐ zhōng tāng, dà jiàn zhōng tāng, gān jiāng fù zǐ tāng, fù zǐ tāng, and sì nì tāng presentations. These formulas treat relatively mild Tài Yīn patterns, but from the perspective of the classic formulas categories we can see that many Tài Yīn disease are commonly quite dangerous, and many deaths occur in the Tài Yīn stage, hence the adage “when there is stomach qì, there is life, and the absence of stomach qì bodes death”. Because Tài Yīn patterns are commonly seen, we need to be knowledgeable about the Tài Yīn classic formulas.

Headache: Two cases by Liu Duzhou 劉渡舟

Headache: Two cases by Liu Duzhou 劉渡舟

Translated by Daniel Eng, L.Ac.

Case 1: Zhenwu tang + Ling gui zhu gan tang

Liu Duzhou
Mr. Li, male, 32 years old. The patient was a driver. When he drove in the summer, the weather was hot and he would freely drink ice-cold beer or soda, daily and without restraint. When autumn came he started experiencing headaches every night. The pain was severe, and he had to knock his fists against his head or take analgesic pills in order to obtain relief; it was also accompanied by blurred vision. The condition had persisted for over a month.
On visual inspection, the patient’s facial complexion was dark and sallow, his tongue was pale and tender with a wet, slippery coating, and his pulse was deep, wiry and moderate. This was a case of yang deficiency with water overflowing, turbid yin escaping upward, and clear yang being stifled.
Fuzi 12g, fuling 18g, baizhu 9g, shengjiang12g, baishao 9g, guizhi 6g, zhi gancao 6g
After taking six packets of the medicine, the headaches had lessened significantly. His formula was changed to Ling gui zhu gan tang, and after four packets he was cured.
Commentary by Dr. Liu: Zhenwu tangis also known as Xuanwu tang.Xuanwu is the spirit that controls water in the north. Because this formula has the function of supporting yang and controlling water, it is therefore named Zhenwu tang; it is used for patterns such as Shaoyin yang deficiency with cold, and water qi failing to transform. The Shanghan lun says: “Abdominal pain and inhibited urination . . . means there is water qi.” This indicates the key pathomechanism of this pattern. Yin deficiency with hyperactive yang often stirs wind, while yang decline with exuberant yin often stirs water—this is a basic rule of the occurrence and development of disease. Yang deficiency stirring water is normally treated with the Ling gui formulas; if the disease has reached the kidneys, with yang qi deficiency and decline, palpitations, dizziness, instability when standing, and swaying as if about to fall to the ground, then we must treat using Zhenwu tang.If one takes Zhenwu tang,and the kidney yang is warmed yet the water qi is still unable to transform completely, then we can further use the warming herbs of the Ling gui formulas to harmonize.

Case 2: Guizhi qu gui jia fuling baizhu tang

Ms. Jin, female, 42 years old. The patient had been suffering from left-sided migraines for over three years. She had tried many treatments without effect. Accompanying symptoms included stiff nape; distention, fullness and discomfort of the chest and epigastrium; and frequent, scanty urination. Bowel movements were normal. The pulse was wiry and tight, and the tongue fur was wet and slippery almost to the point of dripping.
Fuling 30g, baishao 30g, baizhu 10g, zhi gancao 10g, dazao 12 pieces, shengjiang10g.
After taking six packets, she was cured.
Commentary by Dr. Liu: Line 28 of the Shanghan lunsays: “When Guizhi tangis taken, or down-purging is used, and there is still pain and stiffness of the head and nape, feathery-warm heat effusion, no sweating, fullness and slight pain beneath the heart, and inhibited urination, Guizhi qu gui jia fuling baizhu tang masters.” Physicians throughout the ages have had quite different understandings of this line from the original text. For example, Xu Dachun of the Qing dynasty said: “Whenever formulas are modified, it is always the assistant or envoy herb [that is removed]. If the chief herb is removed, a new formula name is given. Here guizhiis removed, yet [the formula] is still named after guizhi;this cannot be explained.” Qian Tianlai also said: “The significance of treatment with Guizhi qu gui jia fuling baizhu tang is unclear. I am afraid that this was the error of a later copyist—it is impossible to know. Even if one uses it, I am afraid that it will not necessarily be effective.” And Wu Qian, the author of the Yizong jinjian, asserted even more directly that “remove guizhi” was erroneously written instead of “remove shaoyao.
So, how should we understand this issue? First, we should remember the features of Guizhi tang and its modifications and transformations. The biggest feature of Guizhi tang is that it moistens yin and harmonizes yang, and the herbal combination that achieves this feature is guizhi combined with shaoyao. Guizhiand shaoyao,one yang and one yin, clinically can be taken to form a dichotomy. For example, there is a Guizhi jia gui tang,so there is also a Guizhi jia shaoyao tang;therefore, since there is a Guizhi qu shaoyao tang,there should also be a Guizhi qu gui tang. This way, yin and yang are counterparts, and this fits the objective rules of disease transformations and their treatments. If we analyze along these lines, Guizhi tang with the removal of guiis actually a real phenomenon.
Furthermore, from the perspective of the herbal composition of Guizhi qu gui jia fuling baizhu tang, it wouldn’t hurt to compare it to Ling gui zhu gan tang,in order to understand more clearly the significance of removing gui.In the Shanghan lun, Zhongjing used Zhenwu tang to support yang and disinhibit water, so he also had Zhuling tang to supplement yin and disinhibit water as its counterpart. This is because fluid metabolism dysfunction in the human body is related to the two aspects of yin and yang. Therefore, since Zhongjing offered Ling gui zhu gan tang to unblock the yang and disinhibit water, he should have a formula to harmonize yin and disinhibit water as its counterpart. The answer to this question lies precisely in Qu gui jia fuling baizhu tang.
This formula’s herbal composition is as follows: fuling, shaoyao, baizhu, zhi gancao, shengjiang and dazao.If we look at these ingredients, it is not difficult to discover that the four ingredients fuling, shaoyao, baizhuand zhi gancao are exactly analagous to the four ingredients of Ling gui zhu gan tang, with guizhiand shaoyao as yin-yang counterparts. For this reason, it wouldn’t hurt to call this “Ling shao zhu gan tang”for the moment. “Ling shao zhu gan tang” uses shaoyaoon one hand to moisten the ying and harmonize yin, and on the other hand in combination with fuling, so it also has the function of removing water qi and disinhibiting urination. So the ability of Ling shao zhu gan tang” to harmonize yin and disinhibit water is in exact yin-yang relationship with the ability of Ling gui zhu gan tang to unblock yang and disinhibit water. And the fact that shengjiang and dazao are further included is just like how Ling gui zhu gan tang also has the adaptations known as Ling gui zao gan tang and Ling gui jiang gan tang.
Even if this is so, why didn’t Zhongjing simply name it “Ling shao zhu gan tang,” instead of naming it Guizhi qu gui jia fuling baizhu tang? There may be two reasons for this. The first is that in Zhongjing’s writings, there is often a paired relationship between lines that appear before and after each other. After all, Line 21 lists Guizhi qu shaoyao tang, so Line 28 goes on to mention Guizhi tang and the method of removing gui. This causes a person to compare, so that they see the difference between “chest fullness” in the line above, and “fullness and slight pain beneath the heart” in the line below.
Secondly, Zhongjing was afraid that later generations, upon seeing “pain and stiffness of the head and nape” and “feathery-warm heat effusion,” would grasp onto guizhi and not let it go, overly insistent on the exterior-releasing function of guizhi; so he emphasized that for this formula we must remove guizhiand keep shaoyao. Therefore, when reading Zhongjing’s books we must search in hidden places to tease out deeper meanings.
In the clinical use of Guizhi qu gui jia fuling baizhu tang, the key to pattern differentiation lies in “inhibited urination.” Inhibited urination is a manifestation of bladder qi transformation dysfunction, leading to water evil stagnating internally. Water evil stagnating internally in the bladder can obstruct the flow of yang qi in its channel. When yang qi is blocked and the channel is inhibited, there may be external signs such as feathery-warm heat effusion and pain and stiffness of the head and nape, so it looks like an exterior pattern but really is not an exterior pattern. When the water evil congeals and binds, blocking the qi mechanism and causing interior qi disharmony, there may be interior signs such as fullness and slight pain beneath the heart, so it looks like an interior excess pattern but really is not an interior excess pattern. Therefore the methods of promoting sweating and down-purging are both inappropriate. The pathomechanism of this pattern is as follows: inhibited urination → water blocking the bladder → external qi obstruction and internal qi binding.
If the key to pattern differentiation is inhibited urination, why don’t we use Wuling san to disinhibit urination? This issue has already been clearly explained by Tang Rongchuan of the Qing dynasty. He said: “Wuling sanis for the qi of Taiyang failing to reach the exterior, so guizhiis used to diffuse the qi of Taiyang; when the qi reaches the exterior, water will descend on its own, and urination will be disinhibited. This formula [Guizhi qi gui jia fuling baizhu tang]is for the water of Taiyang failing to descend, and therefore guizhi is removed, and fulingand baizhu are further added to move the water of Taiyang; when the water descends, the qi will reach the exterior on its own, and signs such as headache and heat effusion will naturally be resolved. Those without sweating can be cured with slight sweating, and therefore Wuling sanmakes special use of guizhito promote sweating; sweating is what disinhibits water. This formula makes special use of fulingand baizhu to disinhibit water; disinhibiting water is what promotes sweating. Actually this is due to the knowledge that water can transform qi, and qi can move water.”
Source: Liu Duzhou, ed., Jingfang linzheng zhinan (Beijing: People’s Medical Publishing House, 2013), pp. 50–53, 126–128.