Huáng Yuán-Yù on Wú Zhū Yú Tāng

Wú Zhū Yú (吳茱萸): Acrid and bitter flavor, warm nature; enters the foot Yángmíng stomach, foot Tàiyīn spleen, and foot Juéyīn liver channels. Warms the centre, drains dampness, opens depression, breaks congealment, descends turbid yin to stop vomiting, and ascends clear yang to stop diarrhea. 

Cold Damage’s Wú Zhū Yú Tāng

Wú Zhū Yú (吳茱萸) 1 shēng

Rén Shēn (人蔘) 3 liǎng

Shēng Jiāng (生薑) 6 liǎng

Dà Zǎo (大棗) 12 pieces

Treats Yángmíng cold damage with a desire to vomit after eating. Normally, stomach qi descends, [which results] in the absence of vomiting on the intake [of food]. [When] stomach qi adversely ascends, this results in vomiting and reduced [food] intake. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng warm the stomach and descend counterflow. [This] treats Juéyīn disease with dry retching, vomiting of foamy drool, and headaches. 

Due to deficiency of the earth, wood becomes stagnant, centre qi is harmed, the stomach ascends as opposed to descending, and turbid qi is upthrusted, resulting in headaches and dry retching. 

When damp qi is congealed and stagnant, this results in vomiting of foamy drool. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and course wood. [This] treats Shàoyīn disease with vomiting, diarrhea, reversal cold of the extremities, vexation, agitation and a desire to die. 

When cold water rebels against the earth, the spleen sinks and the stomach [runs] counterflow, which leads to both vomiting and diarrhea. [When] center qi is depleted, the four limbs lack warmth, resulting in reversal cold of the extremities. [When] yang departs from its root, it disperses and strays without returning, resulting in vexation, agitation and a desire to die. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and ascend that which is sinking. 

In the Jīn Guì [this formula] treats vomiting and chest fullness. [When] the center is deficient and the stomach runs counterflow, turbid qi becomes congested in the chōng vessel, resulting in vomiting and chest fullness. Rén Shēn and Dà Zǎo bank the earth and supplement the center; Wú Zhū Yú and Shēng Jiāng descend counterflow and drain fullness. 

Huáng Yuán-Yù on line 80 of the Shāng Hán Lùn

“伤寒,医以丸药下之,身热不去,微烦者, 栀子干姜汤主之。”

“In cold damage, (which was) treated with a great purging pill; (if) the fever has not abated (and there is) slight vexation, Zhī Zǐ Gān Jiāng Tāng governs”.

This formula treats cold damage following major purgation (manifesting with) body heat and slight vexation.
(Here) major purging has injured center qì, with turbid yīn ascending counterflow, and the generation of stasis, (which) injures the bowels (fǔ organs); this results in obstruction to imperial fire, which is unable to descend, therefore there is body heat and heart vexation. Zhī Zǐ Gān Jiāng Tāng is used, as gān jiāng descends counterflow and warms the center, while zhī zǐ ejects stasis and eliminates vexation.

Zhī Zǐ

Bitter flavor, cold nature; enters the hand shào yīn heart, foot tài yīn spleen, foot jué yīn liver, and foot tài yáng bladder channels.
Clears heart fire and eliminates vexation depression, drains spleen earth and eliminates damp heat. (It) ejects turbid stasis from the chest and diaphragm and cools smokey-yellowing from the skin.

Gān Jiāng

Acrid flavor, warm nature; enters the foot yáng míng stomach, foot tài yīn spleen, foot jué yīn liver, and hand tài yīn lung channels. (Gān Jiāng) dries dampness, warms the center, moves depression, downbears turbidity, supplements and boosts fire (of the) earth, breaks up the absorption of water and grains, warms the spleen, stomach and extremities; regulates yīn and yáng and settles nausea and vomiting; downbears turbid counterflow, calms coughing, lifts desertion and sinking and stops efflux diarrhea.

**Above medicinal info translated from ‘Huáng Yuán-Yù’s Interpretation of Medicinals’ (黄元御药解)

Huáng Yuán-Yù on line 100 of the Shāng Hán Lùn

“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。”

“In cold damage (where) the yáng pulse is choppy, and the yīn pulse is wiry, as a rule there should be urgent abdominal pain; first give Xiǎo Jiàn Zhōng Tāng. If it is not reduced, Xiǎo Chái Hú Tāng governs.”

The liver and gall-bladder are from the same qì. If the gall-bladder fails to descend the cùn pulse will be choppy; if the liver fails to ascend, then the chǐ pulse will be wiry. (When) gall-bladder qì ascends counterflow, and restrains stomach-earth, abdominal pain will be seen in the chest and diaphragm. (If) the liver descends and restrains spleen-earth, abdominal pain will be seen in the abdomen and rib-sides. When wood qì is desiccated and dry, then pain will be urgent. When pathogenic factors are in both the liver and gall-bladder, wind-fire will be depressed, injuring central qì. Xiǎo Jiàn Zhōng Tāng is first used; Yí Táng, Gān Cǎo, and Dà Zǎo supplement spleen essence and moderate urgent pain. Shēng Jiāng, Guì Zhī and Sháo Yào outthrust wood depression and clear wind-fire. If it is not reduced and remains, give (Xiǎo) Chái Hú (Tāng) in order to drain ministerial fire.

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.

Xiǎo Qīng Lóng Tāng from the Zhù Jiě Shāng Hán Lùn

Line 40:

“In cold damage when the exterior has not yet resolved, and there is water qì below the heart, with dry retching, heat effusion, and cough, and possibly thirst or diarrhea, or dysphagia, or inhibited urination and lesser abdominal fullness, or panting, xiǎo qīng lóng tāng (Minor Bluegreen Dragon Decoction) governs”.

In cold damage when the exterior has not yet been resolved and there is water qì below the heart, this will result in the contention of water and cold with cold qì counterflow in the lung manifesting with symptoms of dry retching, heat effusion, and cough. The Acupuncture classic says, “Physical cold with cold rheum damages the lungs”. What this means is that there is contraction of two kinds of cold, and both the center and exterior are damaged, which results in the upward movement of counterflow qì. By administering xiǎo qīng lóng tāng (Minor Bluegreen Dragon Decoction) sweat is effused and water is dissipated. With the steeping of water qì in the interior, several signs can manifest, and therefore it must be resolved and transformed. Cheng Wu-ji.jpeg

Xiǎo Qīng Lóng Tāng (Minor Bluegreen Dragon Decoction)

má huáng (Ephedrae Herba) 3 liǎng (remove nodes), flavor is sweet and warm

sháo yào (Paeoniae Radix) 3 liǎng, flavor is sour and slightly cold

wǔ wèi zǐ (Schisandrae Fructus) ½ shēng, flavor is sour and warm

gān jiāng (Zingiberis Rhizoma) 3 liǎng, flavor is acrid and warm

zhì gān cǎo (Glycyrrhizae Radix preparata) 3 liǎng, flavor is sweet and neutral

guì zhī (Cinnamomi Ramulus) 3 liǎng (remove the bark), flavor is acrid and warm

bàn xià (Pinelliae Rhizoma preparatum) ½ shēng (washed), flavor is acrid and slightly warm

xì xǐn (Asari Herba) 3 liǎng, flavor is acrid and warm.

When cold evils are present in the exterior, without the use of acrid and sweet (medicinals), one would be unable to dissipate them.  Má huáng (Ephedrae Herba), guì zhī (Cinnamomi Ramulus), and gān cǎo (Glycyrrhizae Radix) are acrid and sweet, and can therefore effuse and dissipate cold evils. When there is stoppage of water qì below the heart that fails to move, then the kidney qì will become dry. The Nèi Jīng says, “When the kidneys suffer from dryness, swiftly eat acrid to moisten them”. Gān jiāng (Zingiberis Rhizoma), xì xǐn (Asari Herba), and bàn xià (Pinelliae Rhizoma preparatum) are acrid and can (therefore) move water qì and moisten the kidneys. Coughing counterflow and panting are (the result of) counterflow lung qì.  The Nèi Jīng says, “(When) the lungs desire to be collected (astringed), swiftly eat sour in order to collect them”.  Sháo yào (Paeoniae Radix) and wǔ wèi zǐ (Schisandrae Fructus) are both sour and can collect (astringe) counterflow qì and calm the lungs.

Use one dǒu of water for the eight ingredients above.  First boil the má huáng to reduce the water by two shēng.  Remove the foam collecting on top and add the other ingredients.  Boil until reduced to three shēng, remove the dregs, and take one shēng warm. 

Modifications:

If there is slight diarrhea remove the má huáng and add a piece of ráo huā (Wikstroemia Flos) the size of a chicken egg, and dry fry until red.

With diarrhea one cannot attack the exterior, as when sweat is issued, this will result in distention and fullness. Má huáng effuses yáng, which can lead to the steeping of water into the stomach, inevitably resulting in diarrhea. Ráo huā is able to purge water, and once water is removed, diarrhea will cease. 

If there is thirst, remove bàn xià and add three liǎng of guā lóu gēn (Trichosanthis Radix).

Acrid dries, and bitter moistens. Bàn xià is acrid and can therefore dry fluids, so without thirst it is appropriate.  (Here) there is thirst, and it is therefore eliminated. Guā lóu gēn is bitter and can generate fluids therefore it is added.  

If there is dysphagia, remove má huáng and add one piece of blast-fried fù zǐ (Aconiti Radix lateralis preparata).

The classics say, “when water obtains cold qì, there will be mutual contention amongst them and the person will experience dysphagia”.  Fù zǐ is added to warm and dissipate cold water.  When a person has cold, and sweat is repeatedly effused, this will leave the stomach cold, which will result in the vomiting of roundworms, therefore má huáng is removed out of fear of effusing sweat. 

If urination is inhibited and there is fullness in the lesser abdomen, remove má huáng and add four liǎng of fú líng (Poria).

When there is water amassment in the lower burner that fails to move resulting in inhibited urination and fullness in the lesser abdomen, má huáng is inappropriate as it effuses fluids into the exterior; fú líng discharges amassed water out through the lower, and is therefore used instead. 

Line 40:

If there is panting, remove má huáng and add ½ shēng of xìng rén (Armeniacae Semen amarum), removing the skin and tips.

The Jīn Guì Yào Lüè says, “When a person (suffers) from generalized swelling, one should not add má huáng but instead use xìng rén”.  The reason is that má huáng effuses the yáng. With panting and generalized swelling, water qì is the branch and root of the disease.

Line 41:

“In cold damage when there is water qì below the heart, cough, mild panting, and heat effusion without thirst, (but with) thirst after taking the decoction, this means cold is leaving and (the disease) is about to resolve; xiǎo qīng lóng tāng (Minor Bluegreen Dragon Decoction) governs”.

Cough and mild panting are due to cold water shooting into the lungs. Heat effusion and an absence of thirst are due to an exterior pattern, which has not yet ceased. Xiǎo qīng lóng tāng is given to effuse the exterior and dissipate water. (If) after taking the decoction there is thirst, this means that the interior has been warmed, water qì has been dissipated, and (the disease) is about to resolve.

A Breakdown of thirst in the Shāng hán lùn (傷寒論) by Liú Dù-Zhōu (刘渡舟)

A Mismanaged Case Corrected By Zhāng Jī

Introduction:

ZZJ.jpgThe following is a case presentation for a woman that was treated at my clinic in the spring of 2009.  It starts as what seems like a simple case but proves to be quite the challenge until I delved a little deeper into the classics, specifically the seminal and possibly the oldest medical text Treatise on Cold Damage (Shāng Hán Lùn), with further elucidations by the late great Běijīng physician Hú Xī-Shù (胡希恕,1898-1984).

  

Case:

A 29-year-old female presented at my clinic with abdominal pain she had been suffering with for four years.  Most of her pain was felt in the lower abdomen and occasionally in the peri-umbillical area.  Pain was occasionally alleviated with warm compresses and with mild abdominal massage.  When asked, she was not sure whether warm or cool drinks affected the pain but was sure to be more mindful after our first meeting. The pain was very unpredictable, appearing one day before meals, the next after without one distinct pattern.   She mentioned that she first remembers her pain starting a couple months after a difficult break up from her fiancé and several months of instability at her job.  This initial stress had first affected her sleep, which is basically now under control with the occasional use of sleep medication.  Her appetite fluctuated with her moods, as did her overall energy levels.  Bowel movements were not too affected but had a tendency to be soft.   Urination was unaffected.  Mild nausea was noted but she felt it was insignificant since she has always felt slightly nauseous since her break-up.   Her tongue was slightly pale with a thin coating and her pulse was slightly wiry on deep palpation, otherwise they were both unremarkable.  Aside from the above the symptoms, she was a healthy, active woman, who was at her wits end with this nagging pain.  Various western medications were tried all to no avail. 

I had diagnosed the pattern as a simple Liver-Spleen disharmony and assumed I could treat this with a basic Qì moving, Spleen boosting formula such as the Free and Easy Wanderer powder (Xiāo Yáo Sǎn) from the Imperial Grace Formulary of the Tai Ping Era (He Ji Ju Fang), with the addition of Fructus Amomi (Shā Rén) and Radix Aucklandiae (Mù Xiāng).  I prescribed one weeks worth of 5:1 concentrated powders.

The following week she returned to the clinic and reported that after taking the first dose of herbs there was some rumbling in her abdomen and within an hour the pain returned slightly worse than before she came to see me.  For the next couple of days after taking the herbs she felt tired and her abdominal pain was slightly more pronounced.  All other symptoms remained the same including her tongue and pulse presentations.  

In the past when presented with similar cases of digestive problems due to a Liver-Spleen disharmony when herbal formulas were prescribed correctly, at least some alleviation of symptoms would be noted after a few days.  Now in this particular case, with the slight exacerbation of her symptoms and the fact that she felt weaker, it was clear that I was missing something.  Scouring through the pages of the ‘Treatise on Cold Damage’ I came upon clause 100 where it states;

“In Cold damage, when the Yáng pulse is choppy and the Yīn pulse is wiry, there should be acute abdominal pain.  First administer Xiǎo jiàn zhōng tāng.  If there is no reduction (of symptoms), Xiǎo chái hú tāng governs”.

The use of Minor centre fortifying decoction (Xiǎo jiàn zhōng tāng) was definitely justifiable, as her abdominal pain liked the occasional use of warm compresses and abdominal massage.  These two symptoms will usually warrant a diagnosis of deficiency cold and this is what the above formula treats.  With my initial diagnosis, too much stock was put into her  stagnation and the other symptoms were overlooked.  In addition she had a deep wiry pulse, which is included in the above clause (‘Yīn pulse is wiry’).  In the original clause it states that patients experiencing nausea or vomiting should not take this formula and although she did experience some nausea, I felt it was fine and was merely a manifestation of the Qì depression more than anything else.  A weeks’ worth of Minor centre fortifying decoction granules were prescribed with no additions.

A week later she returned to report that there had been a significant reduction of pain and there were even a couple days where she would forget about her stomach and go about her day pain-free. Her energy was slightly improved but she still felt quite tired most days.  Another two weeks of the same formula were prescribed. 

Two weeks later she returned feeling great.  There was an even greater reduction in the pain (about 80%) and her energy levels were “not a hundred percent, but getting better”.  Another two weeks worth of formula with the addition of Radix Astragali (Huáng Qí) were prescribed in hopes that the condition would resolve. 

Another two weeks past and she returned feeling essentially the same as before.  Most of the abdominal pain was alleviated except for a few occasions and her energy levels were slowly improving.

xiǎo chái hú tāng was prescribed for ten days according to the rule of Clause 100, in the Treatise on Cold Damage where it states;

“If there is no reduction in symptoms, xiǎo chái hú tāng governs”.

Hú Xī-Shù offers his interpretation of this passage in his ‘Discussion and Elucidation on Cold Damage’ (越辩越明释伤寒)[1];

“No reduction of symptoms namely means that after taking xiǎo jiàn zhōng tāng the abdominal pain is not completely resolved.  Now because both xiǎo jiàn zhōng tāng and xiǎo chái hú tāng symptoms exist, we must first treat the interior and afterwards the exterior.  Since xiǎo jiàn zhōng tāng only treated half the condition, we must follow up with xiǎo chái hú tāng to affect a complete resolution of symptoms”

Ten days later my patient returned pain free. She had not had any abdominal discomfort in over eight days.  Her energy has improved and she reported an overall greater sense of wellbeing.  This was followed with another two weeks of Minor Buplureum decoction (xiǎo chái hú tāng) to consolidate her condition by resolving Qi stagnation and further supplementing her Spleen and she was discharged.  On follow up almost one year later, she has not had any major problems with her stomach and the only time she has any discomfort is following days of overindulgence in foods that are known triggers for her. 

Afterthoughts:

In retrospect I believe that my initial diagnosis of a Liver-Spleen disharmony was correct, it was my focus and choice of medicinals that failed to offer a quick resolution of symptoms. As we can see from clause 100 and from the perspective of Hú Xī-Shù, it is clear that the deficiency (of the central burner) must be addressed first and afterwards the stagnation.  As Xú Líng-Tāi says in his Categorization of Formulas from the Discussion of Cold Damage (伤寒论类方) regarding Minor Centre Fortifying Decoction[2];

“The Yáng Qì of the office of the centre (burner) is deficient, thereby allowing wood to overwhelm earth”

What this means to me is that Minor Centre Fortifying Decoction would in fact address a Liver-Spleen disharmony with emphasis on supplementation. Once we are able to bank up and entrench earth, wood would no longer be able to exploit, and as per the original clause, we follow up with a formula to harmonize Liver and Spleen, resolve Qi stagnation and supplement the Spleen such as Minor Buplureum decoction (Xiǎo chái hú tāng).

According to Kē Qín (a Qing dynasty Shang Han expert), Minor Centre Fortifying decoction is a great centre harmonizing pain-relieving formula[3] and proved to be just that in this case.

I believe this case to be a bit of an anomaly as it fit almost too perfect with Zhāng Zhòng Jǐng’s original line and even responded to his predictions.  I used to believe that practicing the classics in this day and age was far too difficult and that pre-modern conditions had nothing to do with the complex, modern maladies our patients present with today.  As I continue to study the classics and apply them in my day to day practice, I find that when we truly begin to look at our cases from a different lens we find these patterns that Zhāng Jī and the great physicians after his time spoke about and are offered numerous opportunities to utilize them and bring them to life. 

[1]胡希恕越辩越明释伤寒, 冯世纶, 中国中医药出版社, 2009.

 [2]伤寒论类方 , 徐灵胎公元1759.

[3]伤寒论翼柯琴

Huáng Qín Tāng [Line 172]

Chéng Wú-Jǐ 成无己

From ‘A commentary on the Annotated Shāng Hán Lùn’ (注解伤寒伦) by Chéng Wú-Jǐ

Line 172 

In a Tài Yáng and Shào Yáng combination disease with spontaneous diarrhea, give huáng qín tāng (Scutellaria Decoction); if there is retching, huáng qín jiā bàn xià shēng jiāng tāng (Scutellaria Decoction plus Pinellia and Fresh Ginger) rules it. 

Commentary: In a Tài Yáng and Yáng Míng combination disease, spontaneous diarrhea is coming from the exterior, and gé gēn tāng (Kudzu Decoction) is given to effuse sweat. In a Yáng Míng and Shào Yáng combination disease, spontaneous diarrhea is coming from the interior, and a chéng qì tāng (Order the Qi Decoction) formula is used to precipitate it. This is a Tài Yáng and Shào Yáng combination disease, and the spontaneous diarrhea is a result of the condition being half in the exterior and half in the interior. Here it would be inappropriate to promote sweat or precipitate, so huáng qín tāng (Scutellariae Decoction) is given to harmonize and resolve the pathogens laying half in the exterior and half in the interior. Retching indicates counterflow of stomach qì so bàn xià (Pinelliae Rhizoma preparatum) and shēng jiāng (Zingiberis Rhizoma recens) are added to dissipate counterflow qì.

Huáng Qín Tāng (Scutellariae Decoction)

huáng qín (Scutellariae Radix) 3 liǎng (9g) [acrid-cold]
zhì gān cǎo (Glycyrrhizae Radix preparata) 2 liǎng (6g) [sweet-neutral]
sháo yào (Paeoniae Radix) 2 liǎng (6g) [sour-neutral]*
dà zǎo (Jujubae Fructus) 12 pieces, broken [sweet-warm]

*In the Běn Cǎo Jīng, sháo yào (Paeoniae Radix) is classified as bitter, and is considered to be mildly cold in the Míng Yī Bié Lù.

Commentary: In vacuity and non-repletion, (the) bitter (flavor) is used to harden, and sour is used to contract. huáng qín (Scutellariae Radix) and sháo yào (Paeoniae Radix) are bitter and sour, and are used to harden and constrain the qì of the stomach and intestines. In weakness and insufficiency, (the) sweet (flavor) is used to supplement. gān cǎo (Glycyrrhizae Radix) and dà zǎo (Jujubae Fructus) are both sweet and can supplement and secure stomach and intestinal weakness.

Simmer the four ingredients above in 1 dǒu of water (2,000ml) until reduced to 3 shēng (600ml). Remove the dregs and take 1 shēng (200ml) heated, twice during the day and one at night. If there is retching, add ½ shēng (100ml) of bàn xià (Pinelliae Rhizoma preparatum) and 3 liǎng (9g) of shēng jiāng (Zingiberis Rhizoma recens)*.

*The Sòng dynasty version does not include this modification but has a separate line for huáng qín jiā bàn xià shēng jiāng tāng (Scutellaria Decoction plus Pinellia and Fresh Ginger).

Tài Yáng flow charts

Digging through some of my papers over the weekend, I found an old chart I have, which gives a breakdown of the patterns found in the Shāng Hán Lún (伤寒论), with corresponding formulas, in a neat little flow chart format.  I decided to translate it this morning as I think it\’s pretty cool.  I\’ve started with the Tài Yáng section, and will finish up the rest in the next few days.  Enjoy!