Chapter Three. Internal heat syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that reduce heat, relieve fire-toxin, cool the blood and generate the body fluids. They are used to treat various internal heat syndromes.
Causes of internal heat can be divided into external and internal causes:
• Internal heat due to external causes includes exterior wind-cold or exterior wind-heat, which can pass through the exterior region (also referred to as the Wei (Defensive) level in Wei-Qi-Ying-Xue differentiation) and enter the interior regions of the body when the Defensive-Qi is weak or weakened by improper treatment. The heat is increased in pathological development at the Qi, Ying and Xue levels. However, some exogenous pathogenic heat or heat-toxin may rapidly develop into an internal heat syndrome without an obvious onset at the Wei (Defensive) level; this is called latent warm-febrile disease.
• Internal heat due to internal causes includes disturbance of the functions of internal organs, most often caused by emotional upset, chronic diseases, improper diet and medication.
Syndromes in warm-febrile diseases
Warm-febrile disease is a collective name for infectious diseases that are caused by exogenous pathogenic heat in different seasons. The pathogenic changes are characterized by a relatively acute onset, heat predominating at all stages, and damage of body fluids and Yin. In clinical practice, it refers to acute infections caused by bacteria, viruses or other pathogenic microorganisms, such as influenza, pneumonia, bronchitis, gastroenteritis and dysentery.
Pestilence is a type of virulent infectious disease caused by heat-toxins, such as epidemic cerebrospinal meningitis, poliomyelitis and severe acute respiratory syndrome (SARS). The warm-febrile diseases develop in the body at four levels, referred to as Wei, Qi, Ying and Xue. In pestilence cases, there is rarely an initial stage, or a very short initial stage, and the heat or heat-toxin can enter the Qi or Ying level and cause internal heat syndromes directly. The warm-febrile diseases are analyzed and identified by the method of Wei-Qi-Ying-Xue differentiation.
1. Syndrome of heat at the Wei level (the Defensive level)
Heat in the Defensive level is equal to exterior wind-heat syndrome discussed in Chapter 1. Although it does not belong in the internal heat syndrome category, it is mentioned here as a reference to offer a complete overview of febrile diseases.
Manifestations
Main symptoms
Fever, slight aversion to wind and cold, sore throat, slight thirst and sweating.
Secondary symptoms
Headache, general aching of the body, cough.
Tongue
Red border and tip with a yellow and thin coating.
Pulse
Rapid and superficial.
Analysis of the syndrome
This syndrome is the initial stage of a warm-febrile disease and is equal to exterior wind-heat syndrome in Eight Principle Differentiation. The pathogenic factors are wind and heat. Their pathway of invasion is the nose and throat to the Lung. The wind-heat disturbs the function of the Lung and its related regions, the superficial parts of the body. In the differentiation of warm-febrile diseases, the term Wei syndrome indicates that the pathogenic factor is at the Wei level.
• When the Defensive-Qi pits its efforts against the pathogenic factor, there is a fever.
• The opening and closing of pores becomes irregular due to dysfunction of the Lung. The patient may therefore have an aversion to wind and cold, and episodes of slight, irregular sweating may occur.
• Since the throat is the gateway of the Lung, and heat easily injures the fluid, sore throat and thirst may be present.
• When the Lung-Qi fails to disperse and descend, cough starts.
• A red tip and border of the tongue and a superficial and rapid pulse indicate that the wind-heat is in the exterior region.
(See Figure 3.1 on page 114.)
Treatment principle: Expel wind, clear heat, regulate the Lung and release the exterior
Herb selection principles and formula composition strategies
• First, herbs that are cold, pungent or aromatic, enter the Lung meridian and clear wind-heat in the Upper-Jiao are selected.
• Second, herbs that are bitter and cold, enter the Upper-Jiao, clear heat and drain heat by promoting urination are selected.
• Along with herbs in the second group, it is equally important to select slightly pungent and warm herbs that can stimulate the Lung-Qi to expel wind, thereby assisting herbs that clear wind-heat in the Upper-Jiao.
• Herbs that regulate the Lung-Qi so as to assist herbs that clear wind-heat as well as stop cough are often used.
• Herbs that nourish the body fluid and Yin of the Lung should be added if the fluid and Yin of the Lung are injured.
• Herbs that tonify the Qi and Yin should be added in the recovery period.
Structure of the formula and selection of herbs
See wind-heat syndrome in Chapter 1.
2. Syndrome of heat at the Qi level
Manifestations
Main symptoms
High fever without chills, perspiration, dry mouth and thirst.
Secondary symptoms
Red face, shortness of breath, scanty urine.
Tongue
Red with a yellow coating.
Pulse
Rapid and forceful.
Associated disorders in western medicine
Acute infections caused by bacteria, viruses or other pathogenic microorganisms.
Analysis of the syndrome
This is the metaphase of warm-febrile diseases. The heat increases inside the body and starts to injure the body fluids. At this level, the heat is very strong and has formed a center in the Lung and Stomach, from where it spreads throughout the entire body. The Qi of the involved organs and regions pits its efforts against the pathogenic heat. The body’s resistance and pathogenic factor are both strong.
• High fever without chill, together with a red face and a rapid and forceful pulse indicate that the heat has already passed the Wei level and entered the Qi level.
• When heat forces the fluid to move out of the body, sweat appears.
• As the intense heat can directly injure the body fluids, patients have intense thirst and a dry feeling in the mouth.
• If the Lung-Qi is unable to disperse and descend properly, there is shortness of breath.
The symptoms and signs at the Qi level are often designated as the Four Extremes, namely extremely high fever, intense thirst, heavy sweating and extremely rapid pulse.
(See Figure 3.2 on page 114.)
Treatment principle: Intensively clear heat, protect the body fluids and vent the pathogenic heat
Herb selection principles and formula composition strategies
• First, herbs that are cold, sweet, salty or pungent, have the function of clearing heat and reducing fire are selected.
• Second, herbs that are sweet and cold, can nourish body fluids and protect the Yin are selected.
• Third, herbs that are pungent and cold, can expel heat, vent heat to the Wei level and eventually eliminate it are used in a small dosage.
CAUTIONS
1. Prevent the development of a smoldering syndrome (hidden-fire syndrome):
The bitter and cold herbs that clear heat should be used with caution. Although they can quickly and strongly clear heat and reduce fire, these herbs cannot be used for a long period of time. With high dosage or long-term usage, patients may develop a smoldering syndrome caused by the side effects of bitter-cold herbs. Because pathogenic heat has a tendency to ascend and cold herbs have a tendency to descend, a severe conflict between cold and heat develops. Cold herbs are able to suppress pathogenic heat when their dosages are very large and the heat has to move downwards. However, as heat does not agree with the cold nature of the herbs, it tries to withdraw but becomes constrained and hides itself in the body. As soon as the patient stops using the cold herbs, the constrained heat is freed from suppression and spreads again. In clinical practice, some chronic infections (e.g. sinusitis, bronchitis, gastroenteritis and urinary tract infection) are the result of using high dosages of cold herbs or antibiotics. Therefore, a small amount of herbs that follow the nature of fire and disperse constrained fire should be used with the bitter and cold herbs in order to clear the heat completely.
2. Protect Yin, Yang and Qi:
Bitter herbs possess a drying property that may injure the Yin of the body, which has already been injured by excess heat. Bitter-cold herbs may injure Stomach-Qi and Yang, and disturb digestion, especially when patients have a weak Spleen or Stomach. Although these herbs should not be used either long term or in large dosages, they can be used together with herbs that protect the Spleen and Stomach.
Structure of the formula and selection of herbs
Chief: Clear heat from the Qi level directly
Shi Gao ( Gypsum)
Shi Gao is pungent, sweet and very cold, and enters the Lung and Stomach meridians. It can powerfully clear heat and reduce fire in the Lung and Stomach, and its pungent nature can disperse the intensive constrained heat. In addition, it can generate body fluids and protect the Yin of the body. It is a perfect ingredient to treat pathological change where the heat is intense at the Qi level.
In a warm-febrile disease, although heat can spread to many organs, Shi Gao, as chief in a formula, clears the heat from the Stomach, the center of Yang and heat of the body, and therefore can effectively reduce heat in the entire body.
Zhi Zi ( Gardeniae fructus) and Ku Zhu Ye ( Bambusae amarae folium)
Zhi Zi is bitter and cold, and enters the San Jiao and Liver meridians. It can be used as chief in the formula if the heat particularly disturbs the Heart and the region of the diaphragm, manifested as irritability, restlessness, insomnia and poor appetite. Zhi Zi can clear the heat and eliminate heat by promoting urination.
Ku Zhu Ye is bitter and cold, and enters the Heart meridian. It can clear the heat in the Heart and increase urination, hence reducing the heat in the Upper-Jiao. It is used if there are symptoms such as irritability, restlessness, a bitter taste in the mouth and scanty urine.
Deputy: Clear the heat, nourish the body fluids and enhance the ability of the chief ingredients
Zhi Mu ( Anemarrhenae rhizoma)
Zhi Mu is bitter and cold but moist in nature. It enters the Lung, Stomach and Kidney meridians. It can nourish the Yin and the body fluids, and clear the heat there. It is often used together with Shi Gao ( Gypsum) and serves as deputy in a formula to enhance the ability of Shi Gao.
Assistant: Nourish the body fluids, clear and disperse the heat, regulate the Qi and reduce the side effect of cold herbs
Sang Ye ( Mori folium) and Pi Pa Ye ( Eriobotryae folium)
Sang Ye and Pi Pa Ye are cold in temperature and both enter the Lung meridian. They can clear the heat and descend the Lung-Qi. They are used when there are symptoms such as cough and shortness of breath due to heat in the Lung. Both are moist in nature. Although they cannot effectively generate the fluid of the Lung, they do not injure this fluid when they regulate the Qi.
Lu Gen ( Phragmitis rhizoma)
Lu Gen is sweet and cold, and enters the Lung and Stomach meridians. It is often used as assistant in the formula to nourish the body fluids, clear heat and relieve thirst. It can soothe the Stomach-Qi and treat nausea and vomiting when heat disturbs the Stomach-Qi and Lung-Qi.
Da Huang ( Rhei rhizoma), Mang Xiao ( Natrii sulfas) and Zhi Shi ( Aurantii fructus immaturus)
These herbs are cold in temperature and all enter the Large Intestine meridian. They can powerfully clear the heat there and purge the accumulation. They can be used for constipation due to excess heat in the intestines and the heat consumes the fluid there. In addition, they can reduce heat from the Lung via the approach of clearing and descending the heat in the related Fu organ, the Large Intestine. This method is often referred to as removing the fuel under a cooking pan.
Dang Shen ( Codonopsis radix) and Ren Shen ( Ginseng radix)
Dang Sheng and Ren Shen tonify the Qi and strengthen the body’s resistance. Ren Shen has a stronger function than Dang Shen. They can be used separately as assistants to tonify the Qi in the formula. The condition where excess heat consumes the Qi is manifested as tiredness, shortness of breath, constant sweating with constant high fever and a forceful pulse that is empty in the deep position.
Dan Dou Chi ( Sojae semen praeparatum)
Dan Dou Chi is pungent and slightly warm, and enters the Lung and Stomach meridians. It can disperse and spread the constrained Qi and heat in the Upper-Jiao. In the formula, it is often used as assistant with bitter and cold herbs that can descend and clear the heat. The combination of pungent and warm with bitter and cold can eliminate the heat completely.
Jin Yin Hua ( Lonicerae flos), Lian Qiao ( Forsythiae fructus) and Bo He ( Menthae herba)
These three herbs are cold in nature. They can strongly clear the heat at the Qi level and remove the heat-toxin. As they also have a dispersing tendency in action and can disperse the constrained heat and Qi, they can clear heat effectively.
Chai Hu ( Bupleuri radix) and Huang Qin ( Scutellariae radix)
Chai Hu is pungent and neutral and Huang Qin is bitter and cold. They are particularly effective in dispersing and reducing the constrained Qi and heat in the Upper-Jiao and the Gall Bladder meridian. They can treat symptoms such as fever, a bitter taste in the mouth, hypochondriac distension, poor appetite and irritability.
Jing Mi (non-glutinous rice) and Gan Cao ( Glycyrrhizae radix)
Jing Mi and Gan Cao enter the Spleen meridian and can protect the Stomach and Spleen from the cold herbs that clear heat at the Qi level. They can also tonify the Spleen-Qi and thereby strengthen body resistance. Porridge made from Jing Mi is light and easily digested. It is recommended as a food in the recovery period of a febrile disease.
Examples of classical formulas
Bai Hu Tang (White Tiger Decoction) 
Source: Shang Han Lun 
Composition
Shi Gao ( Gypsum) 30 g
Zhi Mu ( Anemarrhenae rhizoma) 9 g
Gan Cao ( Glycyrrhizae radix) 3 g
Jing Mi (non-glutinous rice) 9 g
Analysis of the formula
This formula is able to remove excess heat from the Qi level, especially from the Lung and Stomach. The manifestations are high fever without chill, perspiration, dry mouth and thirst, a red face, irritability, shortness of breath, a red tongue with a yellow coating and a rapid and forceful pulse.
In this formula:
• Shi Gao, the chief, is pungent, sweet and very cold. It enters the Lung and Stomach meridians. Shi Gao can powerfully clear the heat and reduce the fire in the Lung and Stomach. It has a pungent nature that can disperse the intensive constrained heat. At the same time, it can generate body fluids and protect the Yin of the body . It is a perfect ingredient to treat pathological change where the heat is intense at the Qi level. In a warm-febrile disease, although heat can spread to many organs, Shi Gao, as chief, clears the heat from the Stomach, the center of Yang and heat of the body, and therefore can effectively reduce heat in the entire body.
• Zhi Mu, the deputy, is bitter and cold but moist in nature. Zhi Mu enters the Lung, Stomach and Kidney meridians. It can nourish the Yin and the body fluids, clear the heat there and is used to enhance the ability of Shi Gao.
• Jing Mi and Gan Cao, the assistants, protect the Stomach and Spleen from the cold herbs. They can also tonify the Spleen-Qi to strengthen body resistance in the fight against pathogenic heat at the Qi level.
Commentary on strategies
• In this formula, Shi Gao clears heat in a direct and indirect way, demonstrating the various strategies to clear heat.
• Herbs that nourish the Yin and body fluids also play a very important role in the formula because the heat will, sooner or later, always consume the body fluids so that the heat increases quickly.
• Moreover, the formula reminds us that although body resistance is still strong at this time, one should not forget to tonify and protect the Spleen because it is the foundation of the body’s resistance.
Liang Ge San (Cool the Diaphragm Powder) 
Source: Tai Ping Hui Min He Ji Ju Fang 
Composition
Lian Qiao ( Forsythiae fructus) 1250 g
Zhi Zi ( Gardeniae fructus) 300 g
Bo He ( Menthae herba) 300 g
Huang Qin ( Scutellariae radix) 300 g
Da Huang ( Rhei rhizoma) 600 g
Mang Xiao ( Natrii sulfas) 600 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 600 g
Dan Zhu Ye ( Lophatheri herba) and honey are added in the prepared formula powder.
Analysis of the formula
This formula is able to clear heat in the Upper-Jiao, the Heart, the Lung and the diaphragm. It is used in the syndrome in which heat-toxin affects these organs and regions. The symptoms are fever, restlessness, dry mouth and throat, thirst, swollen and sore throat, ulcers in the mouth or on the tongue, red face and red eyes, scanty urine and constipation, a red border on the tongue, which is particularly dry in the middle and has a yellow coating, and a rapid and forceful pulse.
In this formula:
• The chief is Lian Qiao. It is bitter and cold but has an aromatic smell. It therefore not only clears heat but also disperses heat. Since it enters the Heart meridian, it specifically clears the excess heat in the Upper-Jiao. Lian Qiao is used in a large dosage as befits the chief in the formula.
• Four herbs form the deputy group. Huang Qin and Zhi Zi clear the heat from the Upper-Jiao. Zhi Zi and Bo He disperse the heat from the Upper-Jiao and treat restlessness, dry mouth and ulcers on the tongue. In addition, Zhi Zi and Dan Zhu Ye can clear the heat from the Heart by increasing urination.
• The assistants are Da Huang and Mang Xiao. They are used to clear heat in the intestines by purging the feces. They assist the herbs that reduce heat in the Lung via the approach of clearing and descending the heat in the related Fu organ, the Large Intestine. This method is often referred as removing the fuel under a cooking pan. In this way, they protect the body fluids from being constantly consumed.
• Zhi Gan Cao and honey serve as assistants and envoys; they can reduce the harsh action of Da Huang and Mang Xiao, and protect the Stomach.
When these herbs are used together, the heat is separated and eliminated, thus cooling down the region above the diaphragm.
Commentary on strategies
This formula demonstrates the strategies of clearing the heat. It not only reduces the heat by cooling and descending, but also by purging the bowel, increasing urination and dispersing the Qi and heat in order to separate and remove the heat. In this way the heat can be eliminated completely.
3. Syndrome of heat at the Ying level (the Nutritive level)
Manifestations
Main symptoms
Fever that worsens at night, severe irritability, restlessness, dryness in the mouth but no desire to drink.
Secondary symptoms
Delirium, vague erythema and purpura.
Tongue
Deep red without coating.
Pulse
Rapid and thready.
Associated disorders in western medicine
Severe infectious diseases.
Analysis of the syndrome
If the pathogenic heat is not eliminated at the Wei or Qi levels, it further invades the deeper level of the body, the Ying level, where the Nutritive substances of the body, such as the Yin, the blood and the essence are involved. In some severe cases, the pathogenic heat invades the Ying level directly, bypassing the first two levels.
This is the later and critical stage of a warm-febrile disease. At this stage, the pathogenic heat is strong but the body’s resistance becomes weak. The body fluids have been severely injured, and the Yin and blood are being consumed. At the same time, the heat has entered the blood and starts to disturb the blood circulation.
• Fever, which is higher in the night, is a specific sign of heat at the Ying level. Because the Yang enters the Ying level in the night, it enhances the strength of the body’s resistance so that it can pit more effort against the pathogenic heat, causing the fever to be higher in the night.
• Dryness in the mouth but with no desire to drink is another sign of heat at the Ying level as the body starts to consume the Yin instead of trying to obtain fluid by drinking.
• When the Heart-Yin and Heart-blood are injured, the Heart-shen is disturbed. Severe irritability and restlessness (even delirium) are the main symptoms of disturbance of Heart-shen.
• When heat consumes the blood and makes the blood thicker, the blood has a tendency to stagnate, manifesting as indistinct erythema and purpura.
• A deep red tongue without coating and a thready and rapid pulse are typical signs of Yin deficiency with heat.
(See Figure 3.3 on page 115.)
Treatment principle: Clear heat, cool the blood, nourish the Yin and vent heat to the Qi level
Herb selection principles and formula composition strategies
• First, herbs that are sweet, salty, bitter and cold, and can strongly reduce fire, cool the blood and nourish the Yin are selected.
• Second, herbs that reduce fire and increase body fluids are selected.
• Along with these two groups, it is equally important to select herbs that can vent the heat to the Qi level, as no matter how deeply the exterior heat has invaded the body, it must be eliminated.
CAUTIONS
1. Protect the Yin, Yang and Qi:
The bitter and cold herbs can intensively reduce heat but the bitterness possesses a drying property that may injure the Yin of the body. Bitter-cold herbs may easily injure the Stomach-Qi and Yang, as well as disturb the digestion, especially when patients have a weakness of the Spleen and Stomach.
2. Disperse and clear the constrained fire:
Herbs that are aromatic, bitter and cold, and can disperse and clear the heat should be used because they can disperse the constrained heat and may help to clear heat effectively and completely.
Structure of the formula and selection of herbs
Chief: Reduce fire, clear heat from the Heart, cool the blood and increase the body fluids and Yin
Da Qing Ye ( Isatidis folium) with Sheng Ma ( Cimicifugae rhizoma)
This combination is often used as a substitute for Xi Jiao ( Rhinoceri cornu)**, which is an important substance to reduce and disperse the heat in the blood in classical formulas. Although Shui Niu Jiao ( Bubali cornu) can substitute for Xi Jiao, it is very expensive and its smell is not pleasant.
Da Qing Ye is bitter, salty and very cold, and enters the Heart and Stomach meridians. Salt enters the blood and bitter and cold can clear heat. This herb can strongly clear the heat, remove heat-toxin and cool the blood. Sheng Ma can be used with Da Qing Ye in a ratio of 1 : 10 to disperse the heat and protect the Stomach-Qi and Spleen-Qi, which become constrained by the downward-moving herbs.
Sheng Di Huang ( Rehmanniae radix)
Sheng Di Huang is sweet and cold. It primarily enters the Heart, Stomach and Kidney meridians. It can effectively clear heat, cool the blood and nourish the Yin. It matches the syndrome perfectly and is often used as chief in formulas that clear the heat at the Ying level.
Ling Yang Jiao ( Antelopis cornu)** and Gou Teng ( Uncariae ramulus cum uncis)
Ling Yang Jiao is salty and cold, and enters the Liver, Heart and Lung meridians. It can effectively reduce the fire from the Heart and Liver, calm the mind and relax the tendons. It is often used as the chief substance in formulas that reduce the heat from the Heart and Liver when the heat disturbs the mind.
Since Ling Yang Jiao is banned, it can be replaced by Shi Jue Ming ( Haliotidis concha) and Qing Dai ( Indigo naturalis) with a small amount of Chai Hu ( Bupleuri radix).
Gou Teng is sweet and slightly cold, and enters the Liver and Pericardium meridians. It can cool the Liver, reduce the fire and relax the tendons. It is used in the condition where the Liver-heat stirs the wind so that patients suffer from dizziness, headache and irritability, and even have convulsions. As its function is not very strong, it is often used in combination with other herbs.
Dan Shen ( Salviae miltiorrhizae radix)
Dan Shen is cold and pungent, and enters the Heart meridian directly. It can cool the blood and reduce the heat in the blood. Its pungent nature disperses and dissolves the congealed blood and promotes blood circulation. It can also disperse constrained Qi in the chest. It is commonly used in combination with other chief herbs to reduce the heat at the Ying level and is a very effective herb to calm the mind and treat restlessness, irritability and a warm sensation in the chest caused by heat in the blood.
Zi Xue Dan (Purple Snow Special Pill)
This patent formula is often used to intensively reduce the excess heat and open the orifices. It is a patent formula for treating closed-up syndrome where high fever, convulsions and mental confusion exist.
Deputy: Increase the body fluids and Yin; disperse the blood stagnation
Mai Men Dong ( Ophiopogonis radix) and Xuan Shen ( Scrophulariae radix)
Mai Men Dong is sweet and cold and Xuan Shen is salty and cold. These two herbs can nourish the Yin and clear the heat. They enhance the ability of the chief ingredients to clear the heat at the Ying level.
Mu Dan Pi ( Moutan cortex)
Mu Dan Pi is bitter, pungent and slightly cold, and enters the Heart and Liver meridians. It can clear heat and cool the blood. The strong point of this herb is that it can disperse and dissolve congealed blood which is formed when the heat consumes the blood and makes it thick, and when the blood circulation is disturbed by heat.
Assistant: Clear heat; disperse and vent heat to the Qi level
Jin Yin Hua ( Lonicerae flos) and Lian Qiao ( Forsythiae fructus)
These two herbs are cold in nature and can strongly clear the heat at the Qi level. In addition, they can disperse the constrained heat and Qi, thus clearing the heat effectively. In the formula to treat heat at the Ying level they are often used as assistants to vent heat from the Ying level to the Qi level, as their aromatic smell can disperse the heat and vent the heat, eventually eliminating it from the body.
Zhu Ru ( Bambusae caulis in taeniam), Chuan Bei Mu ( Fritillariae cirrhosae bulbus) and Zhi Shi ( Aurantii fructus immaturus)
When the pathogenic heat disturbs the Qi movement and consumes the Yin, phlegm might be formed. These three herbs are able to remove phlegm and clear heat. They can be added to the formula as assistants if phlegm-heat is present.
Examples of classical formulas
Qing Ying Tang (Clear the Nutritive Level Decoction) 
Source: Wen Bing Tiao Bian 
Composition
Xi Jiao ( Rhinoceri cornu)** 2 g
Sheng Di Huang ( Rehmanniae radix) 15 g
Xuan Shen ( Scrophulariae radix) 9 g
Mai Men Dong ( Ophiopogonis radix) 9 g
Dan Shen ( Salviae miltiorrhizae radix) 6 g
Huang Lian ( Coptidis rhizoma) 5 g
Jin Yin Hua ( Lonicerae flos) 9 g
Lian Qiao ( Forsythiae fructus) 6 g
Dan Zhu Ye ( Lophatheri herba) 3 g
Analysis of the formula
This formula is devised to clear heat at the Ying level, nourish the Yin and cool the blood. The manifestations are fever that is higher in the night, irritability, restlessness and thirst with no desire to drink. In severe cases, delirium, vague erythema and purpura may appear. Patients may have a red tongue without coating or with a dry, thin coating and a rapid, forceful or thready pulse.
In this formula:
• Xi Jiao and Sheng Di Huang are used as the chief substances. They directly reduce the heat and cool the blood, as well as nourish the Yin.
• Mai Men Dong and Xuan Shen serve as deputies; they nourish the Yin and enhance the abilities of the chief ingredients.
• Five herbs serve as assistants. Dan Shen cools the blood and disperses the blood stagnation, which are the common accompanying pathological changes when there is heat at the Yin level. Dan Zhu Ye and Huang Lian can clear heat and calm the mind. Jin Yin Hua and Lian Qiao can vent the heat to the Qi level as they are aromatic herbs. They clear heat that has been vented from the Ying level in order to eliminate the heat from the body.
Commentary on strategies
This formula demonstrates the principle of treating the heat at the Ying level. Each group of herbs has specific functions:
• Herbs that clear heat and disperse heat are used together.
• Herbs that cool the blood and disperse the stagnation are used together.
• Herbs that clear heat in the Ying level and herbs that vent heat to the Qi level are used together.
Qing Gong Tang (Clearing the Palace Decoction) 
Source: Wen Bing Tiao Bian 
Composition
Xuan Shen ( Scrophulariae radix) 9 g
Lian Zi Xin ( Nelumbinis plumula) 2 g
Dan Zhu Ye ( Lophatheri herba) 6 g
Lian Qiao ( Forsythiae fructus) 6 g
Mai Men Dong ( Ophiopogonis radix) 9 g
Xi Jiao ( Rhinoceri cornu)** 2–5 g
Analysis of the formula and commentary on strategies
This formula is able to clear heat-toxin from the Heart and can nourish the Yin. It is used when the mind is disturbed by heat, and high fever, loss of consciousness and delirium are present.
• Xin means heart in Chinese. In traditional Chinese medicine, the sprout, the kernel, as the heart of a plant, is considered to enter the Heart of the human body. In this formula, this idea presents clearly.
• The first five herbs are all cold in temperature and only the sprouts of the herbs are selected as these are the coldest part of the herbs. They are used to clear heat and reduce the toxin from the Heart and nourish the Yin, hence the name of this formula – Clearing the (Emperor’s) Palace Decoction.
Ling Jiao Gou Teng Tang (Antelope Horn and Uncaria Decoction) 
Source: Tong Su Shang Han Lun 
Composition
Ling Yang Jiao ( Antelopis cornu) ** 4.5 g
Gou Teng ( Uncariae ramulus cum uncis) 9 g
Sang Ye ( Mori folium) 6 g
Ju Hua ( Chrysanthemi flos) 9 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Sheng Di Huang ( Rehmanniae radix) 15 g
Chuan Bei Mu ( Fritillariae cirrhosae bulbus) 12 g
Zhu Ru ( Bambusae caulis in taeniam) 15 g
Fu Shen ( Poriae cocos pararadicis) 9 g
Gan Cao ( Glycyrrhizae radix) 2.4 g
Analysis of the formula
This formula can cool the Liver and calm the wind, nourish the Yin and relax the tendons. It is used when heat affects the Liver and generates wind. The manifestations are high fever, restlessness and irritability, convulsions, impairment of consciousness, a deep red tongue with a dry brown coating, and a wiry and rapid pulse.
When heat is at the Ying level, the main organs involved are the Heart and the Liver. In this formula, treatment is concentrated on cooling the Liver and calming the wind.
• Ling Yang Jiao and Gou Teng are used as chief substances to directly and intensively reduce the heat and therefore extinguish wind.
• Sang Ye and Ju Hua serve as deputies to disperse the wind and heat, and cool the Liver.
• The remaining herbs serve as assistants. The combination of Bai Shao Yao, Gan Cao and Sheng Di Huang can nourish the Yin, clear heat, and ease and relax the tendons. Chuan Bei Mu and Zhu Ru eliminate the phlegm-heat that is produced by the disturbed Qi and water movement, and they may block the meridians. Fu Shen calms the mind and relaxes the tendons.
Commentary on strategies
This formula has a clear structure. The herbs that cool, pacify and soften the Liver are used together for emphasis. They bring about a quick and effective result.
4. Syndrome of heat at the Xue level (the blood level)
Manifestations
Main symptoms
Heat leads to bleeding: fever, which is higher in the night, red eyes, purpura, hematemesis, epistaxis and hemafecia.
Heat generates wind: dizziness, headache and convulsions.
Heat disturbs the mind: occasional coma, restlessness and delirium.
Tongue
Red tongue with a thin coating.
Pulse
Rapid and thready.
Associated disorders in western medicine
Severe infectious disease, primary thrombocytopenic purpura.
Analysis of the syndrome
This is the most critical stage of the warm-febrile diseases. At this stage, the Qi and Yin are seriously injured, and the heat-toxin has already entered the blood and consumed the blood. At the same time, the heat severely disturbs the blood circulation and causes bleeding.
• As soon as the blood leaves its pathway, it accumulates in one place causing blood stagnation.
• In severe cases, when the tendons lose the nourishment of the blood and Yin, the heat may generate Liver-wind, which manifests as convulsion and dizziness.
• The heat may severely disturb the Heart-shen and cause restlessness, palpitations, coma and delirium.
• The tongue and pulse signs indicate the existence of heat and a deficiency of Yin.
(See Figure 3.4 on page 116.)
Treatment principle: Clear heat-toxin, cool the blood, stop bleeding and disperse the congealed blood
Herb selection principles and formula composition strategies
• First, ingredients that are salty and cold, can cool the blood and eliminate heat-toxin should be used in large dosage.
• Second, herbs that are cold in nature, enter the blood level, can cool the blood and stop bleeding should be used in a large dosage. Along with these herbs, it is equally important to select herbs that nourish the Yin.
• Third, herbs that are pungent or having a dispersing ability and can dissolve the stagnation of the blood or prevent blood stagnation should be used.
• Herbs that can calm the mind, settle the wind and remove phlegm should be used if necessary.
CAUTIONS
1. Cool the blood and avoid blood stagnation:
To treat the syndrome of heat in the blood, an important principle is to cool the blood yet avoid blood stasis. The blood, in a normal condition, should circulate smoothly and quietly. Heat may force it to move faster and become unstable; at the same time, heat may consume the blood and cause blood stagnation and bleeding. The cold herbs may make the blood circulation slower but may also cause blood stagnation. To treat heat in the blood, herbs that enter the blood and have cold, pungent and sweet properties are more suitable for use. Their function of not only cooling the blood, but also promoting blood circulation, may prevent blood stagnation.
2. Make a clear differentiation:
Herbs that are bitter and cold in nature and enter the Qi level should not be used because the pathological change is at the blood level, not at the Qi level. Very cold herbs may cause blood stasis and bitterness may dry the blood.
Structure of the formula and selection of herbs
Chief: Reduce heat-toxin, cool the blood, open the Heart orifice and nourish the Yin
Sheng Di Huang ( Rehmanniae radix), Xi Jiao ( Rhinoceri cornu)**, Ling Yang Jiao ( Antelopis cornu)** and Gou Teng ( Uncariae ramulus cum uncis)
These substances have already been discussed in Section 3, Syndrome of heat at the Ying level. They are also used when the heat is at the Xue level under the same principle. As the condition is more severe, the dosages of these ingredients should be larger and they should be applied promptly without hesitation.
As Xi Jiao is banned, it can be replaced by Da Qing Ye ( Isatidis folium) with a small amount of Sheng Ma ( Cimicifugae rhizoma) . The banned Ling Yang Jiao can be replaced by a large amount of Shi Jue Ming ( Haliotidis concha) and Qing Dai ( Indigo naturalis) with a small amount of Chai Hu ( Bupleuri radix) .
Gou Teng is sweet and slightly cold, and enters the Liver and Pericardium meridians. It can cool the Liver, reduce the fire and relax the tendons. It is used in the condition where the Liver-heat stirs the wind so that patients suffer from dizziness, headache and irritability, and even have convulsions. As its function is not very strong, it should be used in large dosage. It is often used in combination with other herbs.
Zi Xue Dan (Purple Snow Special Pill)
This is a patent formula to intensively and quickly reduce heat-toxin and open the orifices. It is used when the heat is at the Xue level and when the mind is disturbed. Since the heat at the Xue level is dangerous and ordinary herbs are not sufficient to remove the heat-toxin quickly, this patent formula can be used promptly in acute conditions.
Bai Shao Yao ( Paeoniae radix lactiflora)
Bai Shao Yao is sour and cold, and primarily enters the Liver meridian. It can nourish the Yin and clear heat, and is used particularly to soften the Liver, nourish the tendons and relieve cramp and convulsions.
Bie Jia ( Trionycis carapax)**
Bie Jia is salty and cold, and enters the Kidney meridian. It reduces deficient heat and tonifies the Kidney-Yin. It is particularly suitable for conditions where the warm pathogenic factor has invaded the Lower-Jiao and the Qi and Yin of the body are severely impaired. These features manifest as evening fever, low-grade fever, warm palms and bone steaming.
Deputy: Cool the blood and stop bleeding; nourish the Yin, calm the mind and settle the wind
Bai Mao Gen ( Imperatae rhizoma), Ce Bai Ye ( Platycladi cacumen), Zhi Mu ( Anemarrhenae rhizoma), Qian Cao Gen ( Rubiae radix), Bai Tou Weng ( Pulsatilla radix), Huai Hua ( Sophorae flos), Di Yu ( Sanguisorbae radix) and Xiao Ji ( Cirsii herba)
These herbs are all cold in temperature and can cool the blood and stop bleeding. Bai Mao Gen and Ce Bai Ye can stop nose bleeds; Zhi Mu, Qian Cao Gen and Bai Mao Gen can treat vomiting of blood; Bai Tou Weng, Huai Hua and Di Yu are particularly effective in stopping bleeding from the intestines; Xiao Ji and Bai Mao Gen can stop bleeding from the urinary tract.
Tian Men Dong ( Asparagi radix), Mai Men Dong ( Ophiopogonis radix), Xuan Shen ( Scrophulariae radix), Hei Zhi Ma ( Sesami semen nigricum) and E Jiao ( Asini corii colla)
These herbs are able to nourish the Yin and reduce heat. Tian Meng Dong and Xuan Shen enter the Kidney meridian, particularly nourish the Kidney-Yin and reduce heat. Mai Men Dong and Xuan Shen can nourish the Heart-Yin and reduce the heat there. Hei Zhi Ma and E Jiao are moistening in nature; they nourish not only the Yin but also the essence and the blood.
Dan Shen ( Salviae miltiorrhizae radix), Huang Lian ( Coptidis rhizoma) and Zhi Zi ( Gardeniae fructus)
Dan Shen is cold and pungent, and primarily enters the Heart meridian. It can cool the blood and reduce heat in the blood. It is commonly used to reduce heat at the blood level and it particularly treats restlessness, irritability and a warm sensation in the chest. Dan Shen is also able to invigorate the blood and remove congealed blood. It is suitable for use when heat consumes the Yin and blood that leads to blood stagnation.
Huang Lian and Zhi Zi are bitter and cold. They enter the Heart and Liver meridians. They can reduce the heat from the Heart and calm the mind so that they can treat restlessness and irritability. Since bitterness has a drying nature, these herbs should be used with herbs that tonify the Yin.
Sang Ye ( Mori folium) and Ju Hua ( Chrysanthemi flos)
These two herbs are light in weight and dispersing in nature. They can spread the Liver-Qi, disperse the heat and assist herbs that calm the Liver-wind. They can treat dizziness, headache and vertigo. They are used together with herbs that calm convulsions.
Assistant: Cool the blood and promote blood circulation
Mu Dan Pi ( Moutan cortex) and Chi Shao Yao ( Paeoniae radix rubra)
Mu Dan Pi is bitter, pungent and slightly cold; Chi Shao Yao is bitter and cold. They can clear heat and cool the blood. The strong points of these herbs are that they can also dissolve congealed blood and promote blood circulation. Blood stasis often occurs when heat consumes the blood and makes blood thick. In addition, heat makes blood move erratically (‘like a river in a storm’) and also leads to blood stagnation. The cold herbs, which are used in the formula to cool the blood and stop bleeding, may also cause blood stagnation directly. Mu Dan Pi and Chi Shao Yao are particularly selected to treat these conditions.
Examples of classical formulas
Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) 
Source: Bei Ji Qian Jin Yao Fang 
Composition
Xi Jiao ( Rhinoceri cornu)** 1.5–3 g
Sheng Di Huang ( Rehmanniae radix) 30 g
Chi Shao Yao ( Paeoniae radix rubra) 12 g
Mu Dan Pi ( Moutan cortex) 9 g
Analysis of the formula
This formula is able to clear the heat from the Xue level. It removes fire-toxin, cools the blood, nourishes the Yin, dispels blood stasis and stops bleeding. It is used for fever, various types of bleeding, erythema and purpura with a deep purple color, thirst and delirium. Patients may have a deep-red tongue with a very dry coating and a rapid and thready pulse.
• Xi Jiao and Sheng Di Huang are used as chief ingredients to clear the heat in the blood directly. Xi Jiao, as well as its substitutes, is able to cool the Heart blood and reduce the fire-toxin.
• Sheng Di Huang is used in a large dosage, and is able to cool the blood and nourish the Yin.
• Mu Dan Pi and Chi Shao Yao are pungent and cold. They are able to cool the blood, reduce the heat and dissolve congealed blood. They are used as assistants in the formula.
Commentary on strategies
Although there are only four ingredients in this formula, it has a clear structure and shows the strategies of treating heat at the blood level. The four ingredients carry out the treatment procedure completely – cool the blood, stop bleeding and prevent stagnation of blood at the same time.
Qing Wen Bai Du Yin (Clear Epidemics and Overcome Toxin Decoction) 
Source: Wen Re Jing Wei 
Composition
Shi Gao ( Gypsum) 180–240 g/60–120 g/24–36 g
Zhi Mu ( Anemarrhenae rhizoma)
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Huang Lian ( Coptidis rhizoma) 12–18 g/6–12 g/3–4.5 g
Huang Qin ( Scutellariae radix)
Zhi Zi ( Gardeniae fructus)
Sheng Di Huang ( Rehmanniae radix) 18–30 g/9–15 g/6–12 g
Xi Jiao ( Rhinoceri cornu)** 18–24 g/9–15 g/6–12 g
Chi Shao Yao ( Paeoniae radix rubra)
Mu Dan Pi ( Moutan cortex)
Dan Zhu Ye ( Lophatheri herba)
Lian Qiao ( Forsythiae fructus)
Xuan Shen ( Scrophulariae radix)
Jie Geng ( Platycodi radix)
The dosages of some herbs are not recorded in the original book.
Analysis of the formula
This formula is able to clear heat at the Qi, Ying and Xue levels together. It can relieve toxicity, cool the blood and drain fire. It is used in pestilence, a kind of virulent infectious disease that is caused by heat-toxins, such as epidemic cerebrospinal meningitis, poliomyelitis and SARS. The syndrome manifests as high fever, intense thirst, severe stabbing headache with nausea, extreme irritability and insomnia. In severe cases, there may be delirious speech, convulsions, erythema and purpura with a deep purple color, vomiting of blood and nose bleeds. The patient may have a deep-red tongue with a dry yellow coating, and a rapid and deep, or rapid, deep and thready pulse.
In this formula:
• Shi Gao, Zhi Mu and Zhi Gan Cao, the main part of Bai Hu Tang (White Tiger Decoction), are used to clear the heat at the Qi level.
• Xi Jiao, Sheng Di Huang, Mu Dan Pi and Chi Shao Yao, the ingredients of Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction), are used to cool the blood and remove heat-toxin from the blood. Together they are considered to be the chief part of the formula.
• Huang Lian, Huang Qin and Zhi Zi are selected from the formula Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity), which can directly drain fire and fire-toxin. Together they are considered to be the deputy part of the formula.
• Xuan Shen can nourish the Yin, drain the fire, cool the blood and reduce heat-toxin. It also serves as a deputy, in particular to enhance the ability of Sheng Di Huang.
• Dan Zhu Ye and Lian Qiao are assistants. They can clear the heat from the Qi level, and therefore can vent the heat from the Ying level to the Qi level.
• Jie Geng is used as envoy. It has an ascending ability, and can disperse the Lung-Qi and convey the rest of the herbs in the formula to the Lung for further spread in the body.
Commentary on strategies
Although this formula is large in size, it is clear in structure and strong in function.
• In the original formula, Shi Gao, Huang Lian, Xi Jiao and Sheng Di Huang are given in large, medium and small dosages. In a critical condition, the large dosages should be given without hesitation. Once the condition has improved, medium or small dosages should be considered since large dosages of cold substances may injure the Qi and Yang of the body.
• In the original formula, dosages were recorded for these four substances only. The rest can be arranged according to treatment need.
5. Syndrome of aftermath of warm-febrile diseases
Manifestations
Main symptoms
Fever that starts in the night and recedes in the morning without sweating, or lingering low-grade fever, bone steaming, tiredness.
Secondary symptoms
Poor appetite, shortness of breath, emaciation, lethargy, red cheeks and lips, difficulty falling asleep.
Tongue
Red with a thin coating.
Pulse
Weak, thready, rapid.
Associated disorders in western medicine
Aftermath of acute infectious diseases caused by bacteria and viruses, such as bronchitis, pneumonia, influenza, fever in pulmonary tuberculosis and chronic fatigue syndrome.
Analysis of the syndrome
The aftermath is a collective term in warm-febrile diseases. It mostly means the aftermath of heat at the Qi, Ying and Xue levels. At this stage, neither the pathogenic heat nor the body’s resistance is strong, the Yin and body fluids are severely injured, but the pathogenic heat still smolders in the Yin region.
In the aftermath of heat at the Qi level, although the body fluids and the Qi are injured, neither the damage nor the symptoms are serious. The recovery period is fairly short. Manifestations include tiredness, poor appetite and difficulty falling asleep, a red tongue with a dry coating and a rapid pulse.
In the aftermath of heat at the Ying or Xue level, the pathogenic heat is no longer strong but it can smolder for quite a long time in the Yin region. The Qi and Yin are severely injured, which also produces heat. It will take a considerable period of time to eliminate the pathogenic heat.
• In the night, the Yang enters into the region of Yin. There it enhances the strength of the body’s resistance so that it can pit more effort against the pathogenic heat, causing the fever to be higher in the night. In the morning, when the Yang returns to the Yang region, the body’s resistance in the Yin region is too weak to fight, and the fever recedes.
• When the Qi and Yin are weak, they are not able to induce sweating, and the Qi pushes the Yin to move out.
• A lingering low-grade fever indicates Qi and Yin deficiency. The Qi is too weak to pit its efforts against the pathogenic heat, causing the heat to smolder in the body.
• Poor appetite and tiredness indicate Qi and Yin deficiency.
• When heat continuously consumes the Yin, the flesh contracts, leading to emaciation.
• The bones are related to the Kidney. If heat injures the Yin, there may be a burning sensation from deep within the bones that radiates to the surface of the body; however, warmth is not palpable.
• When deficient heat ascends, one may have red lips and cheeks.
• When the Heart-Qi and Lung-Qi are deficient, shortness of breath occurs.
• If the deficient heat disturbs the Heart, one may suffer from insomnia.
• A red tongue with a thin coating or without coating, and a weak, thready and rapid pulse indicate heat at the Yin level, and the Yin and Qi are both deficient.
Note
Heat due to Yin deficiency in the internal disorders is termed empty-heat; external pathogenic heat at the Yin level is termed deficient heat.
Treatment principle: Nourish the Yin and body fluids, reduce deficient heat and eliminate exterior pathogenic heat
Herb selection principles and formula composition strategies
• First, herbs that are sweet and cold, or salty and cold, enter the Kidney, Stomach or Lung meridian and can reduce deficient heat from the Yin level are selected, along with herbs that can penetrate to the Yin level and bring out the heat.
• Second, herbs that tonify the Qi and Yin are selected.
• Herbs that promote digestion, soothe the Stomach-Qi and calm the mind are often used.
Structure of the formula and selection of herbs
Chief: Reduce deficient heat
Qing Hao ( Artemisiae annuae herba), Yin Chai Hu ( Stellariae radix) and Bai Wei ( Cynanchi atrati radix)
Although all three herbs can reduce deficient heat in the aftermath of a warm-febrile disease, each herb has specific functions.
Qing Hao is bitter and cold, has a fragrant smell and is light in nature. The fragrant smell and the light nature may disperse constrained Qi and heat; bitterness and cold may reduce heat from the Qi level. It enters the blood, so is able to clear heat in the blood. Although this herb cannot nourish the body fluids and Yin, its functions of dispersing and reducing heat as well as cooling the blood may protect the Yin and body fluids. It is often used in the metaphase and initial phase of febrile disease when the heat is not high but is constrained and there is also stagnation of Qi.
Yin Chai Hu is bitter and cool, and enters the Liver and Stomach meridians. Its functions are similar to those of Qing Hao but it is stronger in descending deficient heat and cooling the blood. It is more suitable for patients who complain of dryness of the throat and mouth, thirst and afternoon fever.
Bai Wei is bitter, salty and cold, and enters the Lung, Stomach and Kidney meridians. It can reduce deficient heat and cool the blood. The strong point of this herb is that it can be used not only for acute febrile diseases, but also for chronic disorders, such as postpartum fever, lingering fever, night sweats and a warm feeling in the palms and soles in febrile diseases.
Di Gu Pi ( Lycii cortex) and Bie Jia ( Trionycis carapax)**
Di Gu Pi is sweet and cold, and enters the Lung, Liver and Kidney meridians. It can reduce deficient heat, especially when heat has consumed the Liver-Yin and Kidney-Yin. These patients have fever in the night, bone steaming, night sweats and irritability. It is often used for treating chronic low-grade fever.
Bie Jia is salty and cold, and enters the Kidney meridian. It is a strong substance to reduce deficient heat and has the function of tonifying Kidney-Yin. It is particularly suitable for conditions where the warm pathogenic factor has invaded the Lower-Jiao and the Qi and Yin of the body are severely impaired. These features manifest as evening fever, low-grade fever, warm palms and bone steaming.
Combination of Qing Hao ( Artemisiae annuae herba) and Bie Jia ( Trionycis carapax)**
Qing Hao and Bei Jia are used as a pair of substances to reduce the heat in the Yin region. Fever that presents in the night but disappears in the morning indicates that the pathogenic heat is in the Yin region and that the Yin is deficient.
Qing Hao is cold and aromatic. It has a dispersing, ascending and penetrating ability. It can vent the heat and expel it from the body. As a Yang herb, it is not able to enter the Yin region to reach the heat there. Qing Hao enters the Yin level under the guidance of Bie Jia.
Bie Jia is salty and cold. It can nourish the Yin of the Kidney and is effective in reducing deficient heat. As a Yin substance in nature, it is not able to vent the heat to the Yang regions and expel it from the body. Bie Jia enters the Yin level and clears heat there; it moves out to the Qi level under the guidance of Qing Hao.
This combination is used particularly to eliminate heat at the Yin level in febrile disease by entering the Yin level first and returning to the Qi level afterwards.
Deputy: Nourish the Yin and the body fluids; tonify the Qi
Bei Sha Shen ( Glehniae radix), Mai Men Dong ( Ophiopogonis radix), Bai Bian Dou ( Dolichoris lablab semen) and Yu Zhu ( Polygonati odorati rhizoma)
These herbs are able to recover the function of internal organs that are impaired by the pathogenic heat.
Bei Sha Shen can nourish the Lung-Yin and Mai Men Dong can nourish the Heart-Yin. Both can also slightly tonify the Qi. Since they are sweet in taste and their sticky tendency may bring some burden to a weak Stomach, dosages should be appropriate if the patient has Stomach-Qi deficiency.
Bai Bian Dou can slightly tonify the Spleen-Qi. As an astringent herb, it can also stabilize the Yin. It is suitable for use in the recovery process of the Spleen. Yu Zhu is another gentle herb that particularly tonifies the Yin of the Stomach. It is very gentle and does not put an extra burden on the Stomach. However, it needs to be used for a reasonably long period of time before tonification of the Stomach-Yin is complete.
Gui Ban ( Testudinis carapax)** and Mu Li ( Ostrea concha)
Gui Ban is salty, sweet and cold, and enters the Kidney and Heart meridians. It nourishes the Yin and strengthens the Kidney, tonifies the blood and calms the mind. It is used when the Yin, essence and blood in the Lower-Jiao are severely injured. It can also reduce the heat and treat bone steaming due to Yin deficiency in warm-febrile disease. Its function of tonifying the Yin is stronger than its function of reducing deficient heat.
Mu Li is salty and slightly cold, and enters the Kidney, Liver and Gall Bladder meridians. It has a gentle function to nourish the Kidney-Yin and reduce deficient heat. The function of this ingredient is to sedate the mind and anchor the Yang. It is used for treating restlessness, palpitations and insomnia.
Ren Shen ( Ginseng radix), Dang Shen ( Codonopsis radix) and Xi Yang Shen ( Panacis quinquefolii radix)
Ren Shen, Dang Sheng and Xi Yang Shen all tonify the Qi. They can be used in the condition of Qi deficiency caused by consumption of excess heat. Ren Shen is the strongest one and is used in a severe case; Dang Shen is a gentle herb that can be used in a mild case. Xi Yang Shen is cold, can tonify the Qi and nourish the Yin. It is more suitable for use when the heat is still obviously strong and the Qi and Yin are severely damaged.
Assistant: Promote digestion and soothe the Stomach-Qi
Hu Huang Lian ( Picrorhizae rhizoma), Mai Ya ( Hordei fructus germinatus), Shen Qu ( Massa medicata fermentata) and Shan Zha ( Crataegi fructus)
Hu Huang Lian is bitter and cold. It can reduce the deficient heat and improve digestion as it enters the Stomach and Large Intestine meridians. This herb is especially effective in treating nutritional impairment in children. The disorder shows poor digestion with abdominal distension and afternoon fever.
Mai Ya, Shen Qu and Shan Zha are able to aid the digestion of wheat and rice, cereals, meat and fat, respectively. They are often used together when the pathogenic heat has injured the Qi of the Spleen and the patients have poor appetite and distension in the abdomen after meals.
Jing Mi (non-glutinous rice) and Gan Cao ( Glycyrrhizae radix)
Jing Mi and Gan Cao can protect the Stomach and Spleen from the cold herbs that clear heat at the Qi level. They can also tonify the Spleen-Qi to strengthen the body’s resistance.
Fo Shou ( Citri sarcodactylis fructus) and Xiang Yuan ( Citri fructus)
These herbs can regulate the Qi in the Middle-Jiao and promote digestion. They are sour and warm, and enter the Liver and Spleen meridians. They are particularly suitable for use when the Liver-Qi attacks the Stomach. This condition often exists at the late stage of a warm-febrile disease when the Yin of the Liver is injured. The manifestations are hypochondriac distension, fullness in the stomach and poor appetite.
Envoy: Harmonize the functions and properties of herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao can harmonize the function and moderate the temperature of the substances in the formula and is often used as envoy.
Examples of classical formulas
Zhu Ye Shi Gao Tang 
Source: Sheng Han Lun 
Composition
Dan Zhu Ye ( Lophatheri herba) 15 g
Shi Gao ( Gypsum) 30 g
Ren Shen ( Ginseng radix) 5 g
Mai Men Dong ( Ophiopogonis radix) 15 g
Ban Xia ( Pinelliae rhizoma) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 3 g
Jing Mi (non-glutinous rice) 15 g
Analysis of the formula
This formula is able to clear heat and generate body fluids, strengthen the Qi and harmonize the Stomach. It is used in the aftermath of a warm-febrile disease at the Qi level. When the greater part of the heat from the Qi level is eliminated, the Qi and body fluids are injured. Heat disturbs the Qi movement and the function of the Stomach, as well as disturbing the mind. The main symptoms are lingering fever, irritability, thirst, dry mouth, lips and throat, poor appetite, occasional vomiting, a red tongue with little coating and a weak, rapid pulse.
In this formula:
• Dan Zhu Ye and Shi Gao are used as chief substances to reduce the heat from the Heart and the Stomach. Shi Gao is also able to generate the body fluid and soothe the Stomach.
• Ban Xia soothes the Stomach-Qi, improves appetite and stops vomiting. As it has a pungent taste and a moving ability, it can reduce the heaviness of the tonifying herbs. Zhi Gan Cao and Jing Mi are able to tonify the Spleen and accelerate the recovery process. These three herbs all serve as assistants.
• Zhi Gan Cao can harmonize the functions and nature of the herbs in the formula and is also used as envoy.
Commentary on strategies
This formula shows us how to protect the Stomach in the process of clearing heat. It emphasizes the importance of recovering the function of the Spleen and Stomach in the aftermath of a warm-febrile disease at the Qi level.
• In the aftermath of a warm-febrile disease, heat injures the Qi and Yin. The Stomach, as the generator of Qi and Yin, is very weak and sensitive.
• In this formula, herbs such as Zhi Gan Cao, Jing Mi and Ban Xia protect the Stomach.
• Ren Shen and Mai Men Dong can strengthen the Middle-Jiao and are not harmful to the weakened Stomach.
• Shi Gao and Dan Zhu Ye are not bitter and cold, but sweet and cold. They clear heat without injuring the Qi and Yin.
Qing Hao Bie Jia Tang (Artemisia Annua and Soft-shelled Turtle Shell Decoction) 
Source: Wen Bing Tiao Bian 
Composition
Qing Hao ( Artemisiae annuae herba) 6 g
Bie Jia ( Trionycis carapax)** 15 g
Sheng Di Huang ( Rehmanniae radix) 12 g
Zhi Mu ( Anemarrhenae rhizoma) 6 g
Mu Dan Pi ( Moutan cortex) 9 g
Analysis of the formula
This formula is able to nourish the Yin, and reduce and vent the deficient heat. It is used when the heat smolders in the Yin region at the later stage of a warm-febrile disease. The manifestations are fever that starts in the night and recedes in the morning without sweating, emaciation without loss of appetite, a red tongue with little coating, and a thready and rapid pulse.
In this formula:
• The combination of Qing Hao and Bie Jia is used to reduce the deficient heat in the Yin regions and bring it out of the Yin level too.
• Sheng Di Huang and Zhi Mu enter the Lower-Jiao, can nourish the Kidney-Yin and reduce the deficient heat. They can enhance the ability of Bie Jia and serve as deputies.
• Mu Dan Pi is also used as deputy because it can particularly reduce the deficient heat in the blood, cool the blood and promote the blood circulation.
• Qing Hao and Bie Jia in combination serve as envoy. Bie Jia brings Qing Hao to the Yin region, then Qing Hao vents the heat to the Yang region and expels the heat.
Commentary on strategies
• The strategy of venting heat from the Yin level is represented by the combination of Bie Jia and Qing Hao which have clearing and dispersing abilities.
• The strategy of tonifying with reducing is demonstrated by using herbs without a cloying nature to nourish the Yin. Since the heat still smolders in the Yin region and many tonifying herbs are too sweet and may retain the pathogenic heat, the combinations of salty, sweet, bitter and pungent tastes with cold temperature may result in an effective strategy to nourish the Yin, reduce the heat and vent the heat.
Qing Gu San (Cool the Bones Powder) 
Source: Zheng Zhi Zhun Sheng 
Composition
Yin Chai Hu ( Stellariae radix) 5 g
Zhi Mu ( Anemarrhenae rhizoma) 3 g
Zhi Bie Jia (processed Trionycis carapax)** 3 g
Di Gu Pi ( Lycii cortex) 3 g
Qing Hao ( Artemisiae annuae herba) 3 g
Qin Jiao ( Gentianae macrophyllae radix) 3 g
Hu Huang Lian ( Picrorhizae rhizoma) 3 g
Gan Cao ( Glycyrrhizae radix) 2 g
Analysis of the formula
This formula is able to reduce deficient heat and is used at the late stage of warm-febrile diseases when there is chronic low-grade fever, bone steaming, irritability and lethargy due to Yin deficiency of the Kidney and Liver with deficient heat.
In this formula:
• Yin Chai Hu, as chief, is bitter and cool, and can effectively reduce the deficient fire from the Yin region without the tendency of excessive drainage.
• Zhi Mu, Di Gu Pi and Zhi Bie Jia serve as deputies; they are able to nourish the Yin and reduce the deficient heat. Since they all enter the Kidney meridian, they can also effectively reduce the bone steaming. Qing Hao and Qin Jiao also serve as deputies; they are effective at dispersing the Qi and venting the heat.
• Hu Huang Lian is used as assistant and can reduce the deficient heat and promote digestion.
• Gan Cao serves as envoy; it can protect the Middle-Jiao and harmonize the substances in the formula.
• Zhi Bie Jia also serves as envoy; it can guide all the substances entering the Yin region. Qing Hao, as another envoy, can vent the heat to the Yang region and expel the heat.
Commentary on strategies
In this formula, although the methods of nourishing and reducing are used together, it focuses on reducing the deficient fire so as to effectively treat the symptom of bone steaming.
San Jia Jian Fu Mai Tang (Modified Restore the Pulse Powder) 
Source: Wen Re Jing Wei 
Composition
Zhi Gan Cao ( Glycyrrhizae radix preparata) 18 g
Sheng Di Huang ( Rehmanniae radix) 18 g
Sheng Bai Shao Yao ( Paeoniae radix lactiflora) 18 g
Mai Men Dong ( Ophiopogonis radix) 15 g
E Jiao ( Asini corii colla) 9 g
Sheng Mu Li ( Ostrea concha) 15 g
Sheng Bie Jia ( Trionycis carapax)** 24 g
Sheng Gui Ban ( Testudinis carapax)** 30 g
Analysis of the formula
This formula is able to nourish the Yin and generate the pulse, anchor the Yang and extinguish the Liver-wind. It is used to treat a condition in a warm-febrile disease where the pathogenic heat is no longer strong, but the Yin of the Kidney and Liver is severely injured. The pathogenic heat is continuing to consume the Yin and the Heart, and the tendons have lost nourishment. The manifestations are palpitations (including chest pain), impaired consciousness, cramp and trembling limbs, dry skin and lips, red cheeks, emaciation, lethargy, a thin and dry tongue, and a rapid and thready pulse.
In this formula:
• Some specific substances are used as chief. They are Mu Li, Bie Jia and Gui Ban, termed the three shells. They can effectively nourish the Yin and blood, reduce the deficient heat, anchor the Yang and extinguish the wind. In this way they directly treat cramp and trembling of limbs.
• A large amount of Zhi Gan Cao is used as assistant to tonify the Qi. This stabilizes the Yin and can directly calm the mind and treat palpitations.
When all of these substances are used together, they can nourish the Yin and blood, leading to anchoring the Yang and extinguishing the wind.
Commentary on strategies
This formula demonstrates three strategies:
• The first strategy is using animal products to nourish the Yin and blood in a severe condition of Yin and blood deficiency. Because animals have blood and flesh and are closer to humans than plants, they can tonify the human body directly and strongly.
• The second strategy is to use a mineral substance. As it is heavy and has a descending tendency, it can better anchor the Yang and calm the mind than plants.
• Sheng means raw in Chinese. In this formula, several substances are used without processing to increase the effect of nourishing the Yin and reducing heat.
Heat in different organs
Note
Heat can stay in different internal organs and cause different symptoms, but the treatment principles and principles of herb selection are the same. Thus these are introduced first.
Treatment principle: Clear heat in the involved organs and meridians; nourish the Yin and body fluids there
Herb selection principles and formula composition strategies
• First, herbs that are bitter and cold or pungent and cold, can directly clear internal heat, and particularly enter the meridians and organs where the heat stays, are selected.
• Second, herbs that enter the externally/internally related meridians and organs to clear heat or to accelerate the function of clearing heat in the related organs are selected.
• Along with the herbs in the second group, it is equally important to use sweet and cold or salty and cold herbs to nourish the Yin.
• Finally, a small amount of pungent herb that has a dispersing property can be used to disperse the constrained heat, thereby assisting the complete and efficient clearing of heat.
• In conditions where the heat enters the blood, herbs that cool the blood should be used.
CAUTIONS
1. Prevent constrained fire:
Most of the herbs that clear heat are bitter and cold. Because bitterness has the tendency of moving downwards, and cold, of course, can clear heat, they can quickly and strongly clear heat and reduce fire in the right situation. However, these herbs cannot be used for a long period of time. With high dosage or long-term use, the bitter-cold herbs may cause a smoldering syndrome, a common side effect of these herbs. Therefore, a small amount of herbs that can disperse the constrained fire can be added to reduce this side effect.
2. Protect Yin, Yang and Qi:
Bitter herbs have a drying nature, which may injure the Yin of the body. Bitter and cold may injure Stomach-Qi and Yang, and disturb digestion. Although these herbs should not be used either long term or in large dosages, they can be used together with herbs that protect the Spleen and Stomach.
6. Syndrome of heat in the Heart and Small Intestine
Manifestations
Main symptoms
Warm sensation in the chest, restless, thirst and a preference for cold drinks, red face, a bitter taste in the mouth and insomnia. In severe cases, loss of consciousness, delirium and bleeding.
Secondary symptoms
Dark urine with a foul smell or accompanied by urgent and painful sensations, ulcers on the tongue, and sores, boils and carbuncles, which are characterized by warmth, swelling, redness and pain.
Tongue
Red with a thin yellow coating.
Pulse
Rapid and forceful.
Associated disorders in western medicine
Insomnia, infectious diseases, infections of the skin such as sores, boils and carbuncles , urinary tract infection.
Analysis of the syndrome
Excess Heart-fire is mostly generated by Liver-fire, its mother organ. The most common cause is emotional disturbance, such as stress and frustration. It may also be caused by the imbalance between Kidney and Heart, such as in shock where the Heart-fire loses control of the Kidney-water. Moreover, some diseases or some drugs can directly injure the Yin of the Heart and cause Heart-fire to ascend, such as in a warm-febrile disease.
• When Heart-fire injures the Yin and body fluids, patients may have thirst and a preference for cold drinks, and a bitter taste in the mouth.
• If heat disturbs the Heart-shen, there might be restlessness, insomnia and a warm sensation in the chest. In a severe case there may even be loss of consciousness and delirium.
• The Heart governs the blood and promotes blood circulation. Heat can easily enter the blood and cause bleeding.
• If Heart-fire influences its external related organ, the Small Intestine, patients may have dark urine with a foul smell which may be accompanied by urgent and painful sensations.
• The Heart opens into the tongue, thus ulcers on the tongue indicate heat in the Heart.
• Heart-fire may generate fire-toxin and cause sores, boils and carbuncles, which are characterized by warmth, swelling, redness and pain.
Treatment principle: Clear heat from the Heart and Small Intestine
Structure of the formula and selection of herbs
Chief: Clear heat, reduce fire-toxin and nourish the Heart-Yin and body fluids
Sheng Di Huang ( Rehmanniae radix) and Da Qing Ye ( Isatidis folium)
Sheng Di Huang is sweet, bitter and cold, and enters the Heart, Liver and Kidney meridians. Its bitterness can reduce fire, cold can clear heat, and cold and sweet together can generate body fluids and Yin, thus effectively controlling fire. Moreover, it also enters the blood, can cool the blood and stop bleeding. Since it matches the three aspects of pathological change of fire of the body, it is the most commonly used herb to reduce fire of the Heart.
Da Qing Ye is salty and very cold, and enters the Heart and Stomach meridians. It can strongly reduce Heart-fire and relieve fire-toxin; it can also cool the blood. It is used to treat severe cases of Heart-fire syndrome. It is also used to treat fire-toxin syndromes, such as infections.
Huang Lian ( Coptidis rhizoma)
Huang Lian is bitter and cold, and primarily enters the Heart and Stomach meridians. It can strongly clear heat and reduce the intense fire from the Heart directly. At the same time, it can also relieve fire-toxin and dry damp-heat. It is suitable for use in cases of sores, boils and carbuncles . As Huang Lian is very bitter and cold, it is not suitable for long-term use, especially in an excess heat syndrome without dampness. As soon as the intense heat is reduced, some gentle, sweet and cold herbs should be used instead of Huang Lian.
Deputy: Nourish the body fluids, clear heat in the related organ and cool the blood
Mai Men Dong ( Ophiopogonis radix)
Mai Men Dong is sweet, slightly cold and bitter, and enters the Heart, Lung and Stomach meridians. It can nourish the Yin, reduce the fire and is commonly used for thirst, dry mouth, warmth in the chest and restlessness.
Mu Tong ( Mutong caulis)*, Dan Zhu Ye ( Lophatheri herba) and Zhi Zi ( Gardeniae fructus)
These three herbs are bitter and cold, and all enter the Heart meridian. They can clear the heat from the Heart and treat restlessness, warmth in the chest and bitterness in the mouth. Moreover, they can lead the heat from the Heart downward and eliminate the heat by increasing urination. Furthermore, these herbs can clear heat in the Small Intestine directly, and treat dark and scanty urine and painful and urgent urination due to damp-heat.
Mu Tong is the strongest of these herbs at clearing heat, but it is very cold, bitter and poisonous. It can only be used for a short period of time to reduce the intensive fire. Dan Zhu Ye is the weakest herb but a safe one. It can be used in a mild or medium case of Heart-fire.
Zhi Zi is the most commonly used herb. It has a stronger function than Dan Zhu Ye and is not a poisonous herb like Mu Tong. As it enters the San Jiao meridian, it can clear the heat from the San Jiao and regulate the water passage, reduce Heart-fire and increase urination to leach out heat.
Dan Shen ( Salviae miltiorrhizae radix)
Dan Shen is bitter and slightly cold, and enters the Heart and Liver meridians. It can effectively clear heat and cool the blood, and is used as deputy when the Heart-fire disturbs the blood and causes blood stagnation. It treats warmth in the chest and restlessness due to the heat in the blood and blood stagnation.
Assistant: Disperse constrained heat, treat the symptoms associated with Heart-fire and protect the Stomach
Lian Qiao ( Forsythiae fructus)
Lian Qiao is bitter and cold, and enters the Heart meridian. It can clear fire and relieve fire-toxin. Lian Qiao has a fragrant smell and thus has an ascending and dispersing tendency in action. As this moving tendency may reduce the chance of a constrained-heat condition forming, it is also used in the formula as a corrective assistant.
Zhu Li ( Bambusae succus) and Lian Zi Xin ( Nelumbinis plumula)
Zhu Li and Lian Zi Xin are very cold and enter the Heart meridian. They can be used if the Heart-shen is disturbed by heat or heat-toxin. They can clear the heat, open up the orifices and revive the spirit. Zhu Li can eliminate phlegm-heat, open the Heart meridian, and treat loss of consciousness, delirium and restlessness.
Dan Shen ( Salviae miltiorrhizae radix)
Dan Shen can be used as assistant in the formula of clearing heat from the Heart. When heat injures the Yin and consumes the blood of the Heart, it makes the blood thicker than normal. At the same time, heat can force the blood to move erratically (‘like a river in a storm’). Both of these conditions may cause blood stagnation. Dan Shen can cool the blood, promote the blood circulation and remove the congealed blood, enabling recovery of the normal condition of blood and its circulation.
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Sheng Gan Cao Shao (tips of Glycyrrhizae radix)
Zhi Gan Cao is sweet and primarily enters the Spleen meridian. It can tonify the Spleen-Qi and moisten dryness; it is used when the heat consumes the Yin and Qi and causes dryness. In addition, it can protect the Stomach from cold herbs, which often conflict with the intense fire and also often suppress the Stomach-Qi.
Sheng Gan Cao, the raw Gan Cao that has not been processed with honey, has a quite different function from Zhi Gan Cao in that it can reduce heat-toxin. Sheng Gan Cao Shao is very thin in shape and is believed to enter the urinary tract; in particular, it can reduce painful, burning and distending sensations in the urinary tract.
Envoy: Harmonize herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet and primarily enters the Spleen meridian. In a formula for reducing heat, it is used to protect the Stomach from heat and from cold herbs. It is also used to harmonize the functions of herbs in a formula.
Examples of classical formulas
Dao Chi San (Guide out the Red Powder) 
Source: Xiao Er Yao Zheng Zhi Jue 
Composition
Sheng Di Huang ( Rehmanniae radix) 3 g
Mu Tong ( Mutong caulis)* 3 g
Dan Zhu Ye ( Lophatheri herba) 3 g
Sheng Gan Cao Shao (tips of Glycyrrhizae radix) 3 g
Analysis of the formula
This formula is able to drain the heat from the Heart and Small Intestine. It treats excess heat in these organs that is manifested as irritability with a sensation of heat in the chest, thirst and a preference for cold drinks, a red face, a bitter taste in the mouth, constipation and scanty and dark urine. Patients may have a red tongue with a thin, dry and yellow coating, and a rapid pulse.
In this formula:
• Sheng Di Huang, the chief, is sweet, bitter and cold, can directly nourish the Yin and reduce the heat.
• Mu Tong and Dan Zhu Ye, the deputies, enter the Heart and Small Intestine meridians and can drain the heat by promoting urination.
• Sheng Gan Cao Shao, the assistant, can reduce heat-toxin and stop the pain and irritation in the urinary tract.
When the four herbs are used together, the excess heat from the Heart can be reduced and leached out.
Commentary on strategies
In this small formula, the strategies are shown by clearing Heart-fire in direct and indirect ways – clear heat from the Heart and from the Small Intestine.
• This formula demonstrates the principle of offering the pathological factor a way to leave the body by using Mu Tong and Dan Zhu Ye to promote urination and leach out heat.
• This formula is also characterized by using the combinations of herbs that clear heat and nourish the Yin, promote urination but avoid the likelihood of injuring the Yin.
Liang Ge San (Cool the Diaphragm Powder) 
See Section 1 above, Syndrome of heat at the Qi level.
Xie Xin Tang (Drain the Epigastrium Decoction) 
Source: Jin Gui Yao Lue 
Composition
Da Huang ( Rhei rhizoma) 6 g
Huang Qin ( Scutellariae radix) 3 g
Huang Lian ( Coptidis rhizoma) 3 g
Analysis of the formula
This formula is able to drain fire-toxin and dry dampness. It is used to treat excess heat in the Heart, which causes high fever, irritability, restlessness, flushed face, red eyes and dark urine; in a severe case, there may be delirious speech. It can also treat damp-heat in the stomach and intestines, which manifests as stomach distension, diarrhea and dysenteric disorders.
In this formula:
• Da Huang is used as chief; it drains the heat and eliminates the heat by purging the intestines and promoting bowel movement.
• Huang Lian and Huang Qin serve as deputies. They are bitter and cold, enter the Heart and Large Intestine respectively, can reduce the heat from the Heart and dry the damp-heat from the Large Intestine.
When these three herbs are used together they may effectively and strongly drain fire-toxin and eliminate dampness.
Commentary on strategies
In this formula, a strategy is used to drain heat-toxin and eliminate the intense heat in the Heart by purging the intestines and promoting bowel movement.
Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity) 
Source: Wai Tai Mi Yao quoted from the formula of Dr Cui 
Composition
Huang Lian ( Coptidis rhizoma) 3–9 g
Huang Qin ( Scutellariae radix) 6 g
Huang Bai ( Phellodendri cortex) 6 g
Zhi Zi ( Gardeniae fructus) 9 g
Analysis of the formula
This formula is able to drain fire and relieve toxicity from San Jiao regions. It is used to treat all kinds of excess heat syndrome, such as high fever, irritability, furuncles and carbuncles, which are considered to be caused directly by the blazing of Heart-fire. Patients have a red tongue with a yellow coating and a rapid and forceful pulse.
In this formula:
• The bitter and cold Huang Lian is used as chief to clear the heat from the Heart directly. It can also clear the heat from the Stomach.
• Huang Qin and Huang Bai, which are also bitter and cold, are used as deputies; they clear the heat from the Upper-Jiao and the Lower-Jiao, respectively.
• Zhi Zi is also used as deputy. Since it enters the San Jiao meridian, it can drain the heat from these three regions and eliminate the heat by promoting urination.
Commentary on strategies
In this formula, all four herbs focus on clearing heat from the Heart, the organ of the blazing fire. They can also clear the heat in different regions, as well as enhancing each others’ functions.
7. Syndrome of heat in the Liver
Manifestations
Main symptoms
Irritability, short temper, bitter or sour taste in the mouth, hypochondriac pain and distension, insomnia, dream-disturbed sleep, headache, dizziness and tinnitus.
Secondary symptoms
Dry, red, painful eyes and blurred vision, irregular menstruation, shortened menstrual cycle, heavy menstruation with fresh red color, swelling of the external genitals or itch in the vagina, turbid and foul smelling leukorrhea and urine, tightness in the chest, sticky sensation in the mouth, distension in the hypochondriac region, eczema and jaundice.
Tongue
Red or red on the border with a yellow coating.
Pulse
Wiry, rapid.
Associated disorders in western medicine
Tympanitis, conjunctivitis, vaginitis, tinea cruris, herpes zoster, eczema, hepatitis and cholecystitis.
Analysis of the syndrome
The Liver is a Yang organ. Anger is the emotion mainly associated with the Liver, which often shows in the pathological conditions.
• Liver-heat or Liver-fire may directly disturb the free flow of Qi, and patients may have a short temper and irritability.
• The Liver opens into the eyes and its taste is remarked as sour; thus Liver-fire can directly cause red and dry eyes, and bitter and sour tastes in the mouth.
• Since the Liver meridian passes the hypochondriac and genital regions, hypochondriac pain and distension may exist when the Qi is obstructed.
• When heat disturbs the Liver, the Liver is unable to house the Hun (soul), and dream-disturbed sleep and insomnia may appear.
• As the Liver and Gall Bladder are externally and internally related, heat in the Liver may directly cause heat in the Gall Bladder. If the heat moves upwards along its meridian, patients may suffer from headache, dizziness and tinnitus.
• When the heat disturbs not only the Qi but also the blood, women may have heavy menstrual flow and a short menstrual cycle.
• If damp-heat accumulates in the Liver meridian, it may bring about symptoms such as swelling of the external genital region or itch in the vagina, eczema, and turbid and foul-smelling leukorrhea and urine.
• If damp-heat accumulates in the Liver and Gall Bladder meridians and obstructs the movement of the Qi and water, patients may feel tightness in the chest, a sticky feeling in the mouth and distension in the hypochondriac region.
• If damp-heat disturbs secretion of bile, jaundice may appear.
• The signs of the tongue and pulse indicate excess heat and damp-heat in the Liver.
Treatment principle: Drain fire from the Liver and Gall Bladder and eliminate damp-heat in the Lower-Jiao
Structure of the formula and selection of herbs
Chief: Reduce Liver-fire intensively and eliminate fire-toxin
Long Dan Cao ( Gentianae radix) and Chuan Lian Zi ( Toosendan fructus)
Long Dan Cao and Chuan Lian Zi are two very bitter and cold herbs, both of which enter the Liver meridian. They can strongly clear heat and reduce fire directly.
Besides intensively draining the fire of the Liver, Long Dan Cao can also dry damp-heat. It is particularly used in conditions where there is excess heat in the Liver that flares upwards and causes disorders in the head and sensory orifices, as well as in conditions where there is damp-heat in the Liver that moves downwards and causes disorders in the Lower-Jiao and the genital area. In a formula to treat acute excess conditions of both Liver fire and damp-heat, Long Dan Cao is often used as chief.
In addition to intensively draining the fire of the Liver, Chuan Lian Zi is able to stimulate the Qi, open the obstruction and therefore effectively relieve pain and distension. However, as it is a poisonous herb, the dosage should be controlled and it should not be used long term.
Deputy: Nourish the Yin and blood, clear heat in the related organ and cool the blood
Bai Shao Yao ( Paeoniae radix lactiflora) and Nu Zhen Zi ( Ligustri lucidi fructus)
Bai Shao Yao is sour, bitter and cold. It primarily enters the Liver meridian. It is able to nourish the Yin and blood of the Liver, and can stabilize the fluid and clear heat. It is a perfect herb to help the chief herb soften the Liver and reduce the fire.
Nu Zhen Zi is sweet, bitter and cold. It enters the Liver and Kidney meridians. It is also able to nourish the Yin and reduce the heat. The strong point of this herb is that it tonifies the Yin without cloying side effects and therefore is particularly suitable for use when damp-heat accumulates in the Liver and its meridian.
Huang Lian ( Coptidis rhizoma) and Zhi Zi ( Gardeniae fructus)
Huang Lian and Zhi Zi are both bitter and cold. They can effectively reduce excess heat from the Liver.
Huang Lian primarily enters the Heart meridian. According to the Five-Element theory, the Liver is the Mother organ of the Heart. One of the strategies to reduce heat is to reduce the Son organ to help the Mother. Huang Lian is thus an appropriate choice for this purpose. In addition, if the heat is active in both organs, Huang Lian is also a good choice as it also enters the Liver meridian.
Zhi Zi enters the San Jiao meridian and is often used to reduce the fire as it can leach the heat out of the body by increasing urination. Due to the same function, it is also very useful for eliminating damp-heat in the Lower-Jiao. Thus Zhi Zi is often chosen to reduce fire as well as eliminate dampness.
Gou Teng ( Uncariae ramulus cum uncis)
Gou Teng is sweet and slightly cold, and enters the Liver and Pericardium meridians. It can clear the heat there and is particularly effective for calming convulsions. When Liver-fire disturbs the Heart, and dizziness, tingling of limbs or convulsions start, it is essential to include Gou Teng in the formula.
Qing Dai ( Indigo naturalis)
Qing Dai is salty and cold, and enters the Liver meridian. As it is able to clear heat and cool the blood, it can be used when Liver-heat disturbs the blood circulation.
Assistant: Disperse constrained heat; treat symptoms associated with heat; protect the Stomach and blood
Xiang Fu ( Cyperi rhizoma) and Chai Hu ( Bupleuri radix)
Xiang Fu and Chai Hu are the most important herbs for promoting Liver-Qi movement. When heat disturbs the Liver-Qi, they can be used in the formula. The difference between them is that Xiang Fu circulates the Qi and Chai Hu disperses and ascends the Qi.
They can both be used as assistants to prevent the constraint of Qi and fire caused by large dosages of cold and descending herbs.
Xia Ku Cao ( Prunellae spica)
Xia Ku Cao is pungent, bitter and cold, and enters the Liver meridian. It can clear heat, tonify the blood and disperse the obstruction. It is effective for treating dizziness, headache and painful eyes. It can also dissipate nodules and is often used for treating distending pain in the breasts due to Liver-fire and phlegm.
Suan Zao Ren ( Ziziphi spinosae semen)
Suan Zao Ren is sweet and sour, and primarily enters the Liver meridian. It can tonify the Liver-blood and improve sleep, and is used to treat restless sleep and dream-disturbed sleep when the heat disturbs the soul.
Dang Gui ( Angelicae sinensis radix) and Bai Shao Yao ( Paeoniae radix lactiflora)
These two herbs are able to tonify the Liver-blood. Dang Gui is bitter, sweet, pungent and warm, can tonify the blood and promote blood circulation. Bai Shao Yao is sour, bitter and cold, can nourish the Yin and soften the Liver. When the heat injures the Yin and blood, and the function of the Liver is impaired, Dan Gui and Bai Shao Yao are often used in combination.
Chi Shao Yao ( Paeoniae radix rubra) and Mu Dan Pi ( Moutan cortex)
These two herbs are cold in nature and enter the Liver meridian. They also enter the blood level. Both can cool the blood and dissolve the congealed blood, thus preventing the heat from consuming the blood and forming congealed blood. The difference between these two herbs is that Chi Shao Yao reduces the excess heat in the blood and Mu Dan Pi reduces the deficient heat in the blood. They can be selected according to syndrome.
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Sheng Gan Cao (raw Glycyrrhizae radix)
Zhi Gan Cao is sweet and primarily enters the Spleen meridian. It can tonify the Spleen-Qi and moisten the dryness; it is used when the heat consumes the Yin and Qi and causes dryness. In addition, it can protect the Stomach from cold herbs, which often conflict with the intense fire and also often suppress the Stomach-Qi.
Sheng Gan Cao, the raw Gan Cao, has a quite different function from Zhi Gan Cao. It can reduce heat-toxin and is often used in a fire-toxin syndrome.
Envoy: Harmonize herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet and primarily enters the Spleen meridian. In a formula to reduce heat, it is used to protect the Stomach from heat and from cold herbs. It is also used to harmonize the functions of herbs in a formula.
Examples of classical formulas
Long Dan Xie Gan Tang (Gentiana Longdancao Decoction to Drain the Liver) 
Source: Xiao Er Yao Zheng Zhi Jue 
Composition
Long Dan Cao ( Gentianae radix) 6 g
Huang Qin ( Scutellariae radix) 9 g
Zhi Zi ( Gardeniae fructus) 9 g
Ze Xie ( Alismatis rhizoma) 12 g
Mu Tong ( Mutong caulis)* 9 g
Che Qian Zi ( Plantaginis semen) 9 g
Dang Gui ( Angelicae sinensis radix) 3 g
Sheng Di Huang ( Rehmanniae radix) 9 g
Chai Hu ( Bupleuri radix) 6 g
Sheng Gan Cao (raw Glycyrrhizae radix) 6 g
Analysis of the formula
This formula can drain excess fire from the Liver and Gall Bladder, and eliminate damp-heat from the Lower-Jiao. It is used to treat up-flaring of Liver-fire, which manifests as headache, red and sore eyes, deafness and tinnitus, hypochondriac pain, a bitter taste in the mouth, irritability, short temper, a red tongue with a yellow coating, and a wiry, rapid and forceful pulse. This formula is also able to eliminate damp-heat in the Liver and Gall Bladder meridians, which manifests as swelling, itchy, wet external genitalia, foul-smelling leukorrhea, difficult and painful urination, a red tongue with a yellow, sticky coating, and a wiry and rapid pulse.
In this formula:
• The very bitter and cold Long Dan Cao is used as chief because it can either drain the fire from the Liver or eliminate the damp-heat from the Lower-Jiao.
• Huang Qin and Zhi Zi, as deputies, enhance the ability of Long Dan Cao to reduce the heat in the Liver and Gall Bladder.
• Ze Xie, Mu Tong and Che Qian Zi are used as assistants to strengthen the function of Long Dan Cao to increase urination and eliminate dampness.
• Sheng Di Huang and Dang Gui are used as corrective assistants to nourish the Yin and blood to treat the injury of Yin and blood caused by excess heat.
• Chai Hu is used as corrective assistant as well as envoy. It can disperse and spread the constraint of Liver-Qi, which is suppressed by the powerful draining herbs. On the other hand, it slightly disperses the heat, thus preventing the development of constrained heat which is often formed in the process of clearing heat. As envoy it harmonizes the herbs entering the Liver and Gall Bladder meridians.
• Sheng Gan Cao is able to reduce heat-toxin and can also harmonize the herbs in the formula.
Commentary on strategies
• This formula reminds us that, in the process of clearing heat, one should not forget to disperse heat, thus preventing the development of constrained heat which is often formed in the process of clearing heat. In this way, heat can be drained out completely and quickly.
• Meanwhile, in the process of clearing heat from the Liver and eliminating dampness, it is also important to strengthen the Yin and promote blood circulation, spread the Liver-Qi and protect the Stomach, as all of them can be disturbed by intense heat and by those very cold herbs.
Chai Hu Qing Gan Tang (Bupleurum Decoction to Clear the Liver) 
Source: Yi Zang Jin Jian 
Composition
Chai Hu ( Bupleuri radix) 4.5 g
Zhi Zi ( Gardeniae fructus) 4.5 g
Lian Qiao ( Forsythiae fructus) 6 g
Huang Qin ( Scutellariae radix) 3 g
Niu Bang Zi ( Arctii fructus) 4.5 g
Dang Gui ( Angelicae sinensis radix) 6 g
Chi Shao Yao ( Paeoniae radix rubra) 4.5 g
Chuan Xiong ( Chuanxiong rhizoma) 3 g
Tian Hua Fen ( Trichosanthis radix) 3 g
Sheng Di Huang ( Rehmanniae radix) 4.5 g
Fang Feng ( Saposhnikoviae radix) 3 g
Gan Cao ( Glycyrrhizae radix) 3 g
Analysis of the formula
This formula can drain the Liver-fire, relieve toxicity, spread the Liver-Qi and strengthen the Spleen. It treats heat in the Liver and Gall Bladder meridians, which manifests as severe headache, flushed cheeks, foul breath, tinnitus, reduced hearing ability, irritability, insomnia, cough with sticky, thick sputum, dark urine, a red tongue and a wiry, rapid pulse.
In this formula:
• Chai Hu and Zhi Zi are used as chief herbs to spread the Liver-Qi and reduce the accumulation of heat in the San Jiao and Gall Bladder meridians, thereby relieving headache, irritability and tinnitus.
• Huang Qin and Lian Qiao reduce the heat in the Upper-Jiao, enhance the ability of the chief herbs and serve as deputies.
• The assistants are divided into three groups according to their function:
– The second group is Dang Gui, Chi Shao Yao and Chuan Xiong; they can promote the blood circulation and reduce pain.
– The third group is Tian Hua Fen and Sheng Di Huang; these herbs nourish the body fluids, reduce the heat and treat dark urine and foul breath.
Commentary on strategies
This formula shows several procedures to treat the excess heat in the Gall Bladder meridian:
• Disperse the constrained heat and the constrained Qi; reduce the clump of heat-toxin.
• Circulate the blood and stop the pain.
• Nourish the Yin.
Since all of the procedures presented in the formula precisely match the pathogenic changes, it can effectively drain the heat-toxin of the Liver and Gall Bladder meridians.
8. Syndrome of heat in the Stomach and Large Intestine
Manifestations
Main symptoms
High fever, sweat, severe thirst, dry mouth, a preference for cold drinks, often feeling hungry, constipation, hemorrhoids.
Secondary symptoms
Headache, toothache, bleeding and swollen gums, very painful and swollen mouth ulcers, foul breath, vomiting of blood, distending pain in the abdomen.
Tongue
Red tongue with a yellow coating.
Pulse
Slippery and rapid.
Associated disorders in western medicine
Aphthae, recurrent aphthous stomatitis, periodontitis, gastritis, constipation.
Analysis of the syndrome
The Stomach and Large Intestine are Yang Ming organs. They are active in receiving and transporting food and drink. All these activities can easily consume the fluids and produce heat. Meanwhile, the pathogenic heat easily and directly disturbs these organs as a result of eating ‘dirty’ food (i.e. food that has not been washed, has been prepared unhygienically, is contaminated, polluted or rotten) or certain dietary habits.
• When there is excess heat in the Stomach and Large Intestine, it can directly consume the body fluids and cause high fever, sweat, severe thirst, dry mouth and constipation.
• Heat can easily and quickly burn out the food, so that patients may complain of feeling hungry all the time.
• Spleen and Stomach associate with flesh. When heat exists in these organs, swollen gums, painful mouth ulcers and foul breath may appear.
• When heat injures the blood vessels, patients may vomit blood and may have hemorrhoids.
• When heat attacks the head along the Stomach and Large Intestine meridians, headache and toothache often occur.
• The disturbance of Qi movement in the abdomen can directly cause distending pain in the abdomen.
Treatment principle: Clear heat in the Yang Ming organs
Structure of the formula and selection of herbs
Chief: Clear heat, nourish the body fluids and reduce fire-toxin
Shi Gao ( Gypsum) and Zhi Mu ( Anemarrhenae rhizoma)
Shi Gao and Zhi Mu are the most commonly used combination to clear excessive, intensive heat.
Shi Gao is pungent, sweet and cold, and enters the Lung and Stomach meridians. It can strongly clear the heat, reduce the fire and generate the body fluids. At the same time, it can disperse heat as it has a pungent property. Since Shi Gao can perfectly match the pathological changes of heat in the body, it is the first choice for treating Stomach-heat.
Huang Lian ( Coptidis rhizoma)
Huang Lian is bitter and cold. Although it primarily enters the Heart meridian, it also enters the Stomach and Liver meridians. It can reduce the heat from the Stomach and treat the sensation of hunger, bitter taste in the mouth and foul breath. It is also suitable for use in heartburn due to Liver-heat attacking the Stomach.
Da Huang ( Rhei rhizoma) and Mang Xiao ( Natrii sulfas)
If the heat accumulates in the Large Intestine and consumes the fluid, constipation may occur. Da Huang and Mang Xiao can be used in the acute condition.
Da Huang is bitter and cold, and can intensively stimulate the intestines to promote bowel movement. From this purgative effect, it eliminates the heat in the intestines. Mang Xiao is salty and cold, can increase the fluid in the intestines and soften the stool. These two substances can enhance each others’ effects. They can effectively clear the heat in the intestines and treat constipation. However, as they are both purgatives they may injure the fluid in the intestines and therefore should not be used for a long period of time.
Deputy: Nourish the body fluids, clear heat in the related organ and cool the blood
Mai Men Dong ( Ophiopogonis radix), Tian Hua Fen ( Trichosanthis radix) and Yu Zhu ( Polygonati odorati rhizoma)
Mai Men Dong, Tian Hua Fen and Yu Zhu are all sweet and cold, and can nourish the fluid in the Stomach. They can be used together or separately.
Mai Men Dong is the strongest of the three to nourish the Yin but is slightly stickier than the other two herbs. Tian Hua Fen is sweet, slightly sour, bitter and cold. It is not sticky and is suitable for treating Stomach-heat syndrome, either in febrile disease or in disturbance of the function of the Stomach. It can effectively relieve thirst and dry mouth. Yu Zhu is very gentle in function and is only suitable for use in a chronic and mild syndrome of Stomach-heat with Yin deficiency.
Zhi Mu ( Anemarrhenae rhizoma) and Xuan Shen ( Scrophulariae radix)
Zhi Mu is bitter and cold, and Xuan Shen is salty and cold. Both can nourish the fluid in the Large Intestine and are often used to treat constipation as they can clear the heat there and soften the feces.
Da Qing Ye ( Isatidis folium), Bai Mao Gen ( Imperatae rhizoma), Di Yu ( Sanguisorbae radix) and Huai Hua ( Sophorae flos)
All four herbs can cool the blood and stop bleeding, and are used in bleeding conditions when the heat forces the blood to leave its normal pathway. Da Qing Ye and Bai Mao Gen can particularly clear Stomach-heat and stop the bleeding there. Di Yu and Huai Hua enter the Large Intestine and treat bleeding in the intestines; they can also be used to treat hemorrhoids.
Assistant: Disperse constrained heat; treat related symptoms caused by heat
Sheng Ma ( Cimicifugae rhizoma) and Mai Ya ( Hordei fructus germinatus)
Sheng Ma and Mai Ya enter the Stomach meridian and are often chosen for ascending the Stomach-Qi as they can reduce the side effects of herbs that intensively reduce Stomach-fire and lead to formation of constrained fire.
Sheng Ma has the function of clearing heat and removing heat-toxin, and is more suitable for use in the condition of heat in the head and face, such as toothache and mouth ulcers. Mai Ya is able to promote digestion and is useful when patients suffer from poor appetite as a result of injury to the Qi and Yin of the Stomach.
Zhu Ru ( Bambusae caulis in taeniam) and Pi Pa Ye ( Eriobotryae folium)
These two herbs can clear Stomach-heat, remove phlegm from the Stomach and soothe the Stomach-Qi. They can be used when the heat disturbs the Qi movement of the Stomach and its digestive function. They can effectively treat nausea, vomiting and poor appetite.
Dang Shen ( Codonopsis radix), Shan Yao ( Dioscoreae rhizoma), Jing Mi (non-glutinous rice) and Zhi Gan Cao ( Glycyrrhizae radix preparata)
These four substances are often used in the recovery period of a febrile disease when the heat has injured the Stomach-Qi. The patient may feel tired and the appetite is poor.
Dang Shen is used in conditions where the Qi is too weak to pit its efforts against the pathogenic heat, the Stomach-heat syndrome lingers and recovery takes a long period of time.
Shan Yao has a similar function to Dang Shen but is gentle. Since it has an astringent taste, it is also able to stabilize the Stomach-Yin and can treat thirst.
Jing Mi is often used to make porridge as it is light to digest and can tonify the Stomach-Qi. Preparation is simple: after cooking the rice with water for 1 hour, the porridge is ready to eat. Jing Mi porridge is the most commonly recommended food during and after a febrile disease.
Zhi Gan Cao is used to tonify the Spleen-Qi and moisten the Stomach. It is also often used to protect the Stomach from the cold herbs that treat heat in the Stomach but which can easily injure the Stomach-Qi and Yang.
Lu Gen ( Phragmitis rhizoma) and Tian Hua Fen ( Trichosanthis radix)
These two herbs are able to nourish the Yin of the Stomach and are used in Stomach-heat syndrome when heat injures the Yin and fluid. Lu Gen is also able to soothe the Stomach-Qi and treats nausea and vomiting when the Stomach-Qi is disturbed by heat and fails to descend.
Zhi Shi ( Aurantii fructus immaturus) and Hou Po ( Magnoliae cortex)
These two herbs are able to regulate the Qi and descend the Qi in the intestines. They reduce the distension of the abdomen and treat constipation, the symptoms that often accompany the condition of Qi and Yin deficiency of the Large Intestine due to heat consumption.
Envoy: Harmonize herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet and primarily enters the Spleen meridian. It is used for harmonizing and moderating the functions of herbs in formulas that clear heat of the Stomach and Large Intestine.
Examples of classical formulas
Qing Wei San (Clear the Stomach Powder) 
Source: Lan Shi Mi Cang 
Composition
Sheng Di Huang ( Rehmanniae radix) 12 g
Dang Gui ( Angelicae sinensis radix) 6 g
Mu Dan Pi ( Moutan cortex) 9 g
Huang Lian ( Coptidis rhizoma) 3–5 g
Sheng Ma ( Cimicifugae rhizoma) 6 g
Analysis of the formula
This formula is used to clear Stomach-fire and cool the blood. It treats toothache due to excess Stomach-fire. This symptom is often accompanied by flushed cheeks, bleeding or swollen gums, foul breath, thirst and a dry mouth. Patients may have a red tongue with a thin yellow coating and a slippery, rapid and forceful pulse.
In this formula:
• The very bitter and cold Huang Lian is used as chief to reduce the heat in the Stomach and dry the dampness in order to relieve pain and reduce the swelling. Since it enters the Heart and Liver meridians, which are the important organs to generate fire in pathological conditions, Huang Lian can strongly and effectively drain the fire.
• Sheng Di Huang, as deputy, can nourish the Yin and cool the blood, enhancing the ability of the chief. Mu Dan Pi is also used as deputy; it can cool the blood and promote blood circulation so that it can relieve the burning pain.
• Mu Dan Pi and Dang Gui are used as assistants in the formula. They promote blood circulation and prevent the stagnation that is caused by the heat-consuming and contracting nature of cold herbs. Sheng Ma also serves as assistant. It enters the Spleen meridian, has an ascending property, can disperse the heat and relieve toxicity in order to assist Huang Lian to drain the heat more effectively.
Commentary on strategies
In this formula, the selected herbs precisely match the physiological and pathological characteristics of the Stomach.
• The herbs that drain the heat and the herbs that disperse the heat are used together.
• The herbs that cool the blood and the herbs that promote blood circulation are used together.
Although there are only five herbs, the formula clearly shows the treatment principles and strategies and it is both a good formula to study and an effective formula to use in clinical practice.
9. Syndrome of damp-heat in the Spleen and Large Intestine
Manifestations
Main symptoms
Damp-heat in the Middle-Jiao: distension in the epigastric region and abdomen, reduced appetite, sticky sensation in the mouth, heavy limbs.
Damp-heat in the Lower-Jiao: loose stools or diarrhea, irregular bowel movement, abdominal pain, abdominal distension, tenesmus and a bearing-down sensation in the abdomen, blood and mucus in the stools.
Secondary symptoms
Eczema or other itchy and weeping skin disorders, Bi syndrome of wind-damp-heat type, poor concentration, slow reactions, inability to study and impaired memory.
Tongue
Red with a yellow, sticky tongue coating.
Pulse
Soft.
Associated disorders in western medicine
Gastroenteritis, dysentery, eczema, stomatitis.
Analysis of the syndrome
The Spleen is regarded as a Yin organ and it is easily injured by exterior damp-heat or cold. If the Spleen fails to transport water and food that has accumulated in the Middle-Jiao, this will eventually generate heat in a Yang constitution. Persistent accumulation of damp-heat in the Middle-Jiao may develop damp-heat in the Large Intestine. Both syndromes have a lingering process of pathological development.
• If damp-heat accumulates in the Middle-Jiao, the transformation and transportation functions of the Spleen are impaired. Patients may suffer from loss of appetite and have a sticky sensation in the mouth.
• When dampness blocks the movement of Qi, patients may suffer from distension in the stomach and abdomen.
• As the Spleen governs the muscles and subcutaneous region of the body, damp-heat in the Middle-Jiao may cause heaviness of the limbs and body, and itchy and weeping skin disorders.
• The Spleen is associated with the ability to study and think. If the Spleen is covered by dampness, individuals may suffer from poor concentration, an inability to study and have impaired memory. When the clear Qi of the Spleen is unable to ascend to support the Heart, one may have difficulty in observation and reactions.
• When damp-heat accumulates in the Large Intestine and obstructs the Qi movement, irregular bowel movement, diarrhea, abdominal pain, abdominal distension, tenesmus and bearing-down sensations may occur.
• If damp-heat injures the blood and the flesh, blood and mucus appear in the stool.
Treatment principle: Promote Qi movement in the San Jiao; separate and eliminate damp and heat
Herb selection principles and formula composition strategies
• Herbs that are pungent and warm, can promote Qi movement in the San Jiao, the Qi and water passages to disperse and transform dampness, so as to separate and eliminate dampness and heat, are selected.
• Aromatic herbs that can penetrate through the dampness and revive the Spleen, and therefore accelerate dampness transformation are selected.
• Herbs that are bitter and cold, can dry dampness and clear heat are used initially, together with herbs that disperse and transform dampness.
• Herbs that are bland and cold, can leach out dampness by promoting urination and purging the intestines are selected when damp-heat accumulates in the Middle- and Lower-Jiao.
• Herbs that tonify the Spleen, promote digestion and regulate the Qi should be selected in chronic conditions.
CAUTIONS
1. Be aware of a long treatment course:
When treating a damp-heat syndrome, patients should be made aware that the treatment course is long. In this syndrome, the Yang pathogenic factor (the heat) is mixed with the Yin pathogenic factor (the dampness) and the lingering dampness holds the heat. They form a complicated condition for treatment. Furthermore, they impair the Spleen and slow down digestive processes. All of these result in a fairly long treatment period.
2. Avoid herbs with a strong action:
To remove damp-heat, herbs with strong actions should be avoided. For instance, if the strong warm and pungent herbs are used, they expel the wind rather than disperse and transform dampness, which is a lingering pathogenic factor. Moreover, the warm and pungent herbs can consume the Yin of the body and make the syndrome more complicated in the long run. Strong bitter and cold herbs should not be used to clear heat as they may easily injure the Spleen-Yang and cause further dampness accumulation.
3. Avoid sweet herbs and food:
Sweet herbs and food can easily retain dampness and they should not be used in the treatment.
Structure of the formula and selection of herbs
Chief: Promote Qi movement in the San Jiao; separate and eliminate damp-heat
Ban Xia ( Pinelliae rhizoma) and Huang Qin ( Scutellariae radix)
The combination of Ban Xia and Huang Qin is commonly used to promote Qi movement in the Upper- and Middle-Jiao.
Ban Xia is pungent and warm, and enters the Lung and Stomach meridians. As it can disperse the Qi, it can therefore eliminate dampness at the same time. It soothes the Stomach-Qi and can reduce the distending sensation in the stomach due to stagnation of the Qi and accumulation of dampness.
Huang Qin is bitter and cold, and enters the Lung and Large Intestine meridians. It can clear heat and dry dampness of these organs.
When these two herbs are used together, the Qi movement becomes active and the dampness and heat can be separated and eliminated more easily. Furthermore, both herbs can dry dampness directly.
Xing Ren ( Armeniacae semen), Bai Dou Kou ( Amomi fructus rotundus) and Yi Yi Ren ( Coicis semen)
These three herbs are used together to disperse, transform and leach out dampness respectively in the San Jiao passage where the Qi and water pass. They treat the condition where damp-heat spreads itself in the Upper-, Middle- and Lower-Jiao.
Xing Ren is pungent, bitter and warm, and enters the Lung and Large Intestine meridians. Its pungent and warm nature can disperse the Lung-Qi and the bitterness can descend the Qi. It can disperse the dampness in the Upper-Jiao and open up the Upper-Jiao.
Bai Dou Kou is also pungent and warm but it enters the Spleen meridian. It can dry the dampness in the Middle-Jiao, regulate the Qi movement and reduce distension.
Yi Yi Ren is bland and slightly cold, and enters the Spleen and Lung meridians. It can eliminate the dampness from the Middle- and Lower-Jiao and clear the heat there by increasing urination.
When these three herbs are used together, they can separate and eliminate dampness, thus allowing the Qi to move freely in the San Jiao passage.
Hou Po ( Magnoliae cortex)
Hou Po is pungent and warm, and enters the Lung, Spleen and Large Intestine meridians. It is an excellent herb to regulate the Qi in the San Jiao passage, and can effectively dissolve phlegm and dampness.
Huang Qin ( Scutellariae radix), Huang Bai ( Phellodendri cortex) and Bai Tou Weng ( Pulsatilla radix)
These three herbs are bitter and cold. They enter the Large Intestine meridian and can dry and eliminate the dampness and clear the heat there.
Huang Qin also enters the Lung and can treat the heat in both meridians and organs. Huang Bai enters the Kidney meridian and can also treat damp-heat in the Lower-Jiao and in the Bladder when there is urgent, painful and frequent urination. Bai Tou Weng particularly treats damp-heat in the Large Intestine. It can clear the heat-toxin and treat bleeding due to injury of the blood and flesh by damp-heat in the intestines.
Since these herbs are very bitter and cold, they may injure the Spleen-Yang and cause further dampness accumulation. They should not be used for too long and they should be used with herbs that protect the Spleen.
Deputy: Regulate the Qi in the San Jiao, eliminate dampness and clear heat
Chen Pi ( Citri reticulatae pericarpium) and Zhi Ke ( Aurantii fructus)
These herbs are pungent in nature and enter the Lung and Stomach meridians. They can promote the Qi movement and remove the dampness and phlegm. The difference between them is that Chen Pi is warm and Zhi Ke is cold in temperature; thus they can be selected separately depending on treatment need.
Huo Xiang ( Agastachis herba) and Pei Lan ( Eupatorii herba)
These two herbs are aromatic and enter the Spleen and Stomach meridians. They are able to penetrate through the dampness and revive the function of the Spleen. They particularly treat dampness in the Middle-Jiao.
Huo Xiang is warm and can disperse and dissolve dampness in the Middle-Jiao. It also enters the Lung meridian and can treat exterior dampness as well. It is used in the syndrome where nausea, vomiting, diarrhea and abdominal cramp are accompanied by fever, chills and a heavy sensation in the body.
Pei Lan is also able to disperse dampness, but it is neutral and gentle. It transforms the dampness and is particularly effective for treating a sticky sensation in the mouth.
Shi Chang Pu ( Acori graminei rhizoma), Yuan Zhi ( Polygalae radix), Zhu Ru ( Bambusae caulis in taeniam) and Yu Jin ( Curcumae radix)
When the Spleen fails to transform food and water, dampness or damp-heat may accumulate. This may obstruct the connection between the Heart and the Spleen and lead to mental disorders, poor memory, inability to concentrate and slow reactions.
These four herbs can eliminate the dampness and they treat dampness or damp-heat that covers the Heart orifice. Shi Chang Pu and Yuan Zhi are warm in temperature; Zhu Ru and Yu Jin are cold. They can be selected in the formula to treat dampness or damp-heat.
Da Fu Pi ( Arecae pericarpium) and Bai Dou Kou ( Amomi fructus rotundus)
These two herbs are able to promote Qi movement and dry dampness from the Spleen and Large Intestine. They are used for abdominal distension and irregular and difficult bowel movement even though the stools are not dry.
Zhi Shi ( Aurantii fructus immaturus) and Bing Lang ( Arecae semen)
These two herbs are able to regulate the Qi and descend the Qi in the intestines. They can be used for Qi obstruction by dampness in the intestines. The main symptoms are distension of the abdomen, and irregular and difficult bowel movement. As their actions are quite strong, they are only used in acute and excess conditions. In chronic conditions, especially in conditions of Spleen-Qi deficiency, they should be used with tonifying herbs.
Yi Yi Ren ( Coicis semen), Tong Cao ( Tetrapanacis medulla) and Hua Shi ( Talcum)
These substances are cold and bland. They can eliminate damp-heat by promoting urination. They can be used in the formula to enhance the ability of separating dampness from heat in the body by increasing urination.
Ma Chi Xian ( Portulacae herba) and Yu Xing Cao ( Houttuyniae herba cum radice)
These herbs have the function of clearing heat and eliminating dampness in the intestines. They are often used to treat diarrhea and abdominal pain due to damp-heat accumulation in the intestines after ingesting polluted food and drink.
Di Yu ( Sanguisorbae radix), Huai Jiao ( Sophorae fructus) and Huai Hua ( Sophorae flos)
Di Yu is bitter, sour and cold. It treats damp-heat in the intestines when heat predominates, which is manifested as bleeding. This herb cools the blood and stops bleeding, and stabilizes and holds the blood. As it can reduce swelling and stop pain, it is suitable for treating external hemorrhoids.
Huai Jiao is cold, and its function is to clear heat and reduce fire in the intestines. Since it moves downwards, it is very effective for treating hemorrhoids and is often added to creams for topical use.
Huai Hua is slightly cold. Its ability to clear heat and cool blood is not as strong as the other two herbs, but its functions of stopping bleeding and dispersing heat are stronger than those of Huai Jiao. It is an important herb for treating dysentery and hemorrhoids.
Assistant: Eliminate dampness; tonify Spleen; promote digestion and regulate the Qi
Fang Feng ( Saposhnikoviae radix), Qin Jiao ( Gentianae macrophyllae radix) and Cang Zhu ( Atractylodis rhizoma)
These three herbs are pungent and all have dispersing functions, particularly that of eliminating dampness. They are mainly used for dampness accumulation in the muscles, which is associated with dysfunction of the Spleen when dampness obstructs the meridians.
Fang Feng is pungent and slightly warm, and enters the Spleen meridian. It can disperse wind-dampness, ascend the clear Qi of the Spleen and eliminate the dampness from the muscles and subcutaneous region. It treats heaviness and uneasy sensation in the muscles. Fang Feng can also promote digestion in the sense of reducing distension from the intestines.
Qin Jiao is pungent, bitter and neutral, and enters the Stomach and Large Intestine meridians. As it is able to slightly induce sweating, it can disperse dampness in the superficial region of the body. It treats stiffness, heaviness and pain of the muscles.
Cang Zhu is very pungent and warm. It can directly dry the dampness in the Middle-Jiao. As it can also slightly induce sweating, it can disperse wind and dampness from the superficial region of the body.
Han Fang Ji ( Stephaniae tetrandrae radix) and Yi Yi Ren ( Coicis semen)
These two herbs are able to eliminate damp-heat, increase urination and relax the tendons and muscles. They can be used to treat Bi syndrome due to damp-heat in the Middle-Jiao when burning, heavy and painful sensations of muscles are present.
Bai Bian Dou ( Dolichoris lablab semen), Fu Ling ( Poria) and Bai Zhu ( Atractylodis macrocephalae rhizoma)
These herbs are able to tonify the Spleen-Qi as well as eliminate dampness from the Middle-Jiao.
Bai Bian Dou not only has a very gentle function of tonifying the Spleen-Qi but is also able to transform dampness. Because it is an astringent herb it can stabilize the fluid in the intestines. This herb is particularly useful for treating chronic diarrhea due to Spleen-Qi deficiency and dampness accumulation in the Middle-Jiao.
Fu Ling is bland and neutral, and enters the Spleen and Bladder meridians. It is able to tonify the Spleen and leach out dampness from the Middle- and Lower-Jiao by promoting urination.
Bai Zhu can directly dry dampness in the Middle-Jiao as it is pungent and warm, and enters the Spleen meridian directly. It has a relatively strong function in tonifying the Spleen-Qi compared with the other two herbs. It is often used in the syndrome where dampness accumulates in the Middle-Jiao when the Spleen-Qi is too weak to transform and transport it.
Fo Shou ( Citri sarcodactylis fructus), He Ye ( Nelumbinis folium), Sha Ren ( Amomi xanthioidis fructus), Mai Ya ( Hordei fructus germinatus) and Shen Qu ( Massa medicata fermentata)
These herbs are able to promote digestion, regulate the Qi in the Middle-Jiao and revive the function of the Spleen and Stomach. They are often used in the recovery period of syndromes of damp-heat in the Spleen and Large Intestine.
Fo Shou is also able to spread the Liver-Qi and is more suitable for treating distension in the stomach and hypochondriac regions, and patients with a depressive mood.
He Ye has a light fragrant smell and can revive the Spleen so as to eliminate dampness and improve appetite.
Sha Ren is pungent and warm, and enters the Spleen, Large Intestine and Kidney meridians. In particular, it can relieve distension in the abdomen and treat Qi stagnation with dampness in the Large Intestine.
Mai Ya and Shen Qu are often selected to treat poor appetite because they aid the digestion of wheat, rice and cereal products, respectively.
Ku Shen ( Sophorae flavescentis radix), Di Fu Zi ( Kochiae fructus) and Bai Xian Pi ( Dictamni cortex)
These herbs are bitter and cold, are able to clear heat and transform dampness from the Middle- and Lower-Jiao, increase urination and eliminate dampness. They are mainly used for treating skin disorders, where red, itchy and weeping skin lesions are often present.
Ku Shen enters the Heart meridian and can treat heat in the Heart; the heat is also transported to the Small Intestine. It has the strongest function of clearing damp-heat among these three herbs and it can effectively treat infectious skin diseases caused by bacteria, viruses, scabies and fungi.
Di Fu Zi is pungent in nature and enters the Kidney and Bladder meridians. It is able to expel wind and can effectively stop itch, particularly in the genital area. It is also effective for treating painful urinary dysfunction.
Bai Xian Pi enters the Spleen and Stomach meridians. It can effectively reduce damp-heat in the Middle-Jiao and reduce jaundice.
Envoy: Slow down the action of pungent herbs
Zhi Gan Cao ( Glycyrrhizae radix preparata)
In formulas that treat damp-heat, as the chief, deputy and assistant herbs are not harsh in action or extreme in temperature, an envoy is not usually necessary. Zhi Gan Cao, the most commonly used envoy, is not suitable for use in this case as sweetness may hold onto and generate dampness. However, Zhi Gan Cao is sometimes used to slow down the action of pungent herbs and leads to a steady and lasting result of eliminating dampness.
Examples of classical formulas
Xie Huang San (Drain the Yellow Powder) 
Source: Xiao Er Yao Zheng Zhi Jue 
Composition
Honey and alcohol processed
Fang Feng ( Saposhnikoviae radix) 120 g
Shi Gao ( Gypsum) 15 g
Zhi Zi ( Gardeniae fructus) 6 g
Huo Xiang ( Agastachis herba) 21 g
Gan Cao ( Glycyrrhizae radix) 90 g
Analysis of the formula
This formula can drain and treat smoldering fire in the Spleen which is caused by dampness accumulation. The disorder results in mouth ulcers with foul breath, frequent thirst and hunger, and a dry mouth and lips. Patients may have a red tongue with a yellow and sticky coating and a rapid pulse.
In this syndrome, the Yang pathogenic factor (the fire) is caused by the Yin pathogenic factor (the dampness) and they bring a dilemma to the treatment. In order to reduce heat, cold herbs should be used, but they may injure the Spleen-Yang and further generate dampness in the Middle-Jiao that blocks the Qi movement, and, finally, increases the smoldering fire. For treating dampness, pungent and warm herbs should be used, but they may increase heat in the Middle-Jiao. This formula shows us how to deal with this complicated condition.
Commentary on strategies
To treat a complicated condition where the pathogenic factors are opposite in nature, this formula outlines a strategy to separate them and eliminate them without causing side effects on the body.
• First of all, Fang Feng, in most cases, is used to expel wind and release exterior syndrome. In this formula, it is used to disperse and ascend the constrained Qi and therefore disperse the smoldering heat in the Spleen.
• Secondly, the combination of herbs that have a descending and an ascending nature can activate the Qi, thus effectively reducing heat and dampness.
• Finally, the special processing procedure carries out the same treatment principle and leads to a steady and effective therapeutic result.
Bai Tou Weng Tang (Pulsatilla Decoction) 
Source: Shang Han Lun 
Composition
Bai Tou Weng ( Pulsatilla radix) 15 g
Huang Bai ( Phellodendri cortex) 12 g
Huang Lian ( Coptidis rhizoma) 4–6 g
Qin Pi ( Fraxini cortex) 12 g
Analysis of the formula
This formula is able to clear heat, eliminate heat-toxin, cool the blood and stop diarrhea. It is used to treat heat-toxin and dampness accumulation in the intestines; however, it obstructs Qi and injures the blood. The manifestations are abdominal pain, tenesmus, a burning sensation around the anus, diarrhea containing more blood than pus, and thirst. Patients often have a red tongue with a yellow coating, and a wiry and rapid pulse. In this syndrome, heat predominates and is manifested in the amount of blood in the stool and the burning sensation around the anus.
In this formula:
• Bai Tou Weng is chosen as chief to directly reduce the heat and cool the blood. As it enters the Large Intestine meridian, it can effectively clear heat-toxin there.
• Huang Lian and Huang Bai are deputies. They are bitter and cold, and enter the Middle- and Lower-Jiao, respectively. They can effectively clear the heat and dry the dampness in the intestines.
• Qin Pi serves as assistant; it is bitter, cold and astringent, can clear heat and eliminate dampness, as well as bind up the intestines to stop diarrhea. It is an essential herb in the treatment of chronic conditions where diarrhea lasts for a long time and the Spleen-Qi has been injured.
Commentary on strategies
This formula is only described in order to demonstrate the treatment for a typical syndrome of damp-heat in the intestines. In clinical practice, this formula should be used with variation.
In acute and excess conditions, Qin Pi should not be used. Some herbs should be added, such as:
• Di Yu ( Sanguisorbae radix) and Huai Hua ( Sophorae flos) , which can enhance the ability of Bai Tou Weng to cool the blood
• Zhi Ke ( Aurantii fructus) and Fang Feng ( Saposhnikoviae radix), which can moderate the Liver-Qi and reduce the urgent, frequent bowel movements and tenesmus
• Jing Jie ( Schizonepetae herba) and Lian Qiao ( Forsythiae fructus), which can open the obstruction of Qi and blood.
Shao Yao Tang (Peony Decoction) 
Source: Bao Ming Ji 
Composition
Bai Shao Yao ( Paeoniae radix lactiflora) 15–20 g
Dang Gui ( Angelicae sinensis radix) 9 g
Gan Cao ( Glycyrrhizae radix) 5 g
Huang Lian ( Coptidis rhizoma) 5–9 g
Huang Qin ( Scutellariae radix) 9 g
Mu Xiang ( Aucklandiae radix)** 5 g
Bing Lang ( Arecae semen) 5 g
Da Huang ( Rhei rhizoma) 9 g
Rou Gui ( Cinnamomi cassiae cortex) 2–5 g
Analysis of the formula
This formula can regulate Qi and blood, clear heat-toxin and eliminate dampness in the intestines. It treats the damp-heat-toxin accumulation in the intestines. The Qi and blood are injured and obstructed. The manifestations are abdominal pain, tenesmus, difficult defecation, diarrhea containing mucus and blood in equal amounts, and a burning sensation around the anus. Patients have a red tongue with a yellow, sticky coating and a rapid pulse. In this syndrome, the heat and dampness are equal in strength and are manifested in the equal amount of blood and mucus in stools. The heat-toxin shows in the burning sensation around the anus.
In this formula:
• Bai Shao Yao is used in a large dosage as the chief to tonify the blood and soften the Liver.
• The functions of the chief are enhanced by several groups of deputy herbs:
– Dang Gui, which tonifies the blood and promotes the blood circulation.
– Gan Cao, which can moderate and ease the muscles, thus relieving abdominal pain.
– Huang Qin and Huang Lian, which can directly clear heat and dry the dampness in the intestines.
– Mu Xiang and Bing Lang, which can promote the Qi movement in the intestines and relieve abdominal pain and tenesmus.
• Da Huang, a bitter and cold purgative herb, serves as assistant. It assists Huang Qin and Huang Lian to purge the heat in the process of clearing the heat, and assists Mu Xiang and Bing Lang to purge the damp-heat-toxin accumulation in the intestines.
• Rou Gui, which is sweet and warm, is used as a corrective assistant to prevent the bitter and cold herbs injuring the Yang, which often occurs when the Qi and blood have been weak for a long time. It can also assist Dang Gui to reinforce the action of promoting blood circulation.
Commentary on strategies
This formula shows a clear structure in composition and function from selecting different groups of herbs.
• It treats dysfunction of Qi and blood at the same time, and treats heat and cold, excess and deficiency at the same time. This is demonstrated in the use of warm herbs and cold herbs together, with emphasis on using cold herbs for a heat syndrome.
This formula suggests the following strategies for treating damp-heat in the intestines:
• Regulate the blood in order to stop the bleeding; this strategy is represented by using Bai Shao Yao, Dang Gui and Rou Gui.
• Regulate the Qi in order to relieve tenesmus; this strategy is represented by using Mu Xiang, Bing Lang and Da Huang.
10. Syndrome of heat in the Lung
Manifestations
Main symptoms
Fever, sweat, cough with green sputum, chest pain, shortness of breath, wheezing, thirst and a preference for cold drinks, dry nasal passages and dry lips.
Secondary symptoms
Sore throat, hoarseness, nose bleeds, skin rashes, irregular and difficult bowel movement and distending pain in the abdomen.
Tongue
Red in the front part of the tongue, yellow coating.
Pulse
Superficial and forceful in the Lung position, or rapid and slippery.
Associated disorders in western medicine
Bronchitis, pneumonia, common cold, influenza and constipation.
Analysis of the syndrome
In traditional Chinese medicine, the Lung is considered to be a light, thin and fragile organ. Heat and cold may easily injure this organ.
• When heat invades the Lung and disturbs its dispersing and descending functions, patients may have cough, chest pain, shortness of breath and wheezing.
• The symptom of dryness appears quickly if the fluid of the Lung is injured. Patients may feel thirsty, and have dry nasal passages and dry lips.
• Since skin is related to the Lung, skin rashes may appear when wind-heat invades the Lung.
• The throat is the gateway of the Lung and the excess heat in the Lung may also bring such symptoms as sore throat and hoarseness. When heat injures the blood vessels, nose bleeds may occur.
• When the Lung-Qi is unable to disperse and descend, the Qi movement in the Large Intestine can be blocked too. The main disorders are irregular and difficult bowel movements and pain in the abdomen.
Treatment principle: Clear the heat in the Lung
Structure of the formula and selection of herbs
Chief: Clear heat and reduce fire and fire-toxin of the Lung
Shi Gao ( Gypsum)
Shi Gao is pungent, sweet and very cold. It enters the Lung and Stomach meridians. This mineral substance is often selected as chief because it can intensively reduce the heat and at the same time generate the body fluid in the Lung. It matches the pathological change of heat in the Lung perfectly and is often used in the acute period when the heat invading the Lung has already injured the fluid of the Lung, or has a tendency to injure the fluid there.
Huang Qin ( Scutellariae radix) and Sang Bai Pi ( Mori cortex)
Huang Qin and Sang Bai Pi are bitter and cold, and enter the Lung meridian. They can clear heat and descend the fire from the Lung, and treat cough, thirst and shortness of breath.
Huang Qin can clear damp-heat by blocking the San Jiao passage so that the Lung-Qi is not able to descend. In this situation, there may be a sense of fullness in the chest, restless, irritability and reduced appetite. Huang Qin is often used together with Ban Xia ( Pinelliae rhizoma) and Chai Hu ( Bupleuri radix) to regulate the Qi.
Sang Bai Pi is able to clear heat, direct the Lung-Qi downwards and remove phlegm. It can drain the water from the Lung and promote urination. It is selected in the formula if there is shortness of breath and cough due to Lung-Qi obstruction or fluid accumulation in the Lung.
Deputy: Nourish the body fluids, clear the heat in the related organ and cool the blood
Tian Hua Fen ( Trichosanthis radix) and Lu Gen ( Phragmitis rhizoma)
Tian Hua Fen and Lu Gen are sweet and cold, and enter the Lung and Stomach meridians. They are often used in the syndrome of excess heat in the Lung when the heat has injured the fluid and causes dryness in the Lung. Both herbs can clear heat, generate the body fluids and relieve thirst, dry cough, chest pain and dryness in the mouth.
Gua Lou Ren ( Trichosanthis semen) and Zhi Shi ( Aurantii fructus immaturus)
Gua Lou Ren and Zhi Shi are cold in temperature. Both can clear heat in the Lung and Large Intestine, remove phlegm in the Lung and at the same time promote bowel movement. They are principally selected in the formula to treat cough with green sputum and fullness in the chest and abdomen. They can descend the Qi in the intestines, as well as treating constipation.
Sheng Di Huang ( Rehmanniae radix) and Bai Mao Gen ( Imperatae rhizoma)
Sheng Di Huang and Bai Mao Gen are sweet and cold. They can clear heat and cool the blood, and can be used for bleeding conditions when the heat has injured the blood in the Lung, such as nose bleeds and expectoration of bloody sputum. Moreover, both herbs are able to nourish the Yin and increase body fluids. They are used in the syndrome where the heat has already injured the blood and consumed the Yin and fluid of the Lung.
Assistant: Disperse the constrained heat and treat related symptoms caused by the heat; protect the Lung and Stomach
Jie Geng ( Platycodi radix)
Jie Geng has an ascending nature and enters the Lung meridian. It is often used to disperse the Lung-Qi and reduce the smoldering heat in the Lung, which is the result of obstruction of the Lung-Qi by excess heat and by using strong herbs to clear heat and descend the Qi.
Pi Pa Ye ( Eriobotryae folium), Gua Lou ( Trichosanthis fructus) and Chuan Bei Mu ( Fritillariae cirrhosae bulbus)
These three herbs are cold in temperature, can clear heat, direct the Qi downwards and remove phlegm from the Lung. They are used for treating cough, shortness of breath and expectoration of green sputum.
Bai He ( Lilii bulbus)
Bai He is sweet, bland and slightly cold, and enters the Lung and Heart meridians. It can nourish the Yin and slightly tonify the Qi of the Lung and Heart. It is selected in the formula to reduce excess and deficiency of heat in the Lung when the pathogenic heat has injured the Yin and Qi in a febrile disease. Patients’ main complaints are of a warm, blocked sensation in the chest, restlessness and depression, a dry cough, insomnia and dream-disturbed sleep.
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao can tonify the Qi, together with cold herbs to generate the Yin and body fluids. It can protect the Lung and Stomach from the cold herbs as its sweet taste can smooth and moderate the function and speed of the cold herbs.
Envoy: Harmonize herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet and can harmonize the function of herbs in a formula. However, it should not be used if there is excessive phlegm in the Lung because sweetness may easily keep hold of the phlegm.
Examples of classical formulas
Xie Bai San (Drain the White Powder) 
Source: Xiao Er Yao Zheng Zhi Jue 
Composition
Sang Bai Pi ( Mori cortex) 30 g
Di Gu Pi ( Lycii cortex) 30 g
Gan Cao ( Glycyrrhizae radix) 3 g
Jing Mi (non-glutinous rice) 15–30 g
Analysis of the formula
This formula can drain the heat from the Lung and relieve wheezing. It is used to treat heat in the Lung and the body fluid if the Lung is injured. The manifestations are cough, wheezing, feverish sensation that worsens in the afternoon, a dry mouth, a red tongue with a yellow coating and a thready and rapid pulse.
In this formula:
• Sang Bai Pi is used as chief; it is sweet and cold, enters the Lung meridian, and can strongly, effectively and safely drain the heat of the Lung and protect the fluid there.
• Di Gu Pi serves as deputy; it can enter the Lung and Kidney meridians and can directly enter the Yin level. It can therefore effectively reduce smoldering heat of the Lung and empty-heat from the Kidney.
• Jing Mi and Gan Cao tonify the Stomach and Spleen, and strengthen the Middle-Jiao so as to generate the Yin and Qi of the Lung. This strategy is referred to as cultivating the Earth and generating the Metal.
Commentary on strategies
• This formula is characterized by reducing the mild smoldering heat in the Lung rather than clearing the excess heat or nourishing the Yin of the Lung.
• It is used for the late stage and the recovery stage of warm-febrile diseases, and a mild syndrome of cough and wheezing due to mild smoldering heat in the Lung, such as in the recovery period of bronchitis in children.
Wei Jing Tang (Reed Decoction) 
Source: Bei Ji Qian Jin Yao Fang 
Composition
Lu Gen ( Phragmitis rhizoma) 30 g
Yi Yi Ren ( Coicis semen) 30 g
Dong Gua Zi ( Benincasae semen) 24 g
Tao Ren ( Persicae semen) 9 g
Analysis of the formula
This formula clears heat from the Lung, eliminates phlegm and discharges pus. It is used to treat lung abscess, which is caused by heat-toxin in the Lung and the heat injures the organ and flesh that form the abscess. The symptoms are cough and expectoration of foul-smelling sputum that may be streaked with blood, slight fever, mild chest pain, a red tongue with a yellow and sticky coating, and a slippery and rapid pulse.
In this formula:
• Lu Gen, which is sweet and cold, and enters the Lung and Stomach meridian, is used as chief to transform the phlegm and discharge pus. The strong point of this herb is that it can nourish the fluid of the Lung as well as remove the phlegm and pus from the Lung at the same time. It is particularly useful in the situation where heat has injured the fluid and damaged the flesh.
• Yi Yi Ren is sweet and cold, and enters the Lung and Spleen meridians. It is used as deputy to dissolve the damp-heat from the Upper- and Middle-Jiao.
• Dong Gua Zi, as assistant, is used in large dosage to eliminate phlegm and pus. It enhances the abilities of Lu Gen and Yi Yin Ren.
• Tao Ren is used as assistant to promote blood circulation and break up congealed blood. When the blood circulates properly, the healing process starts. Tao Ren is pungent and warm, and can disperse heat, thus reducing the constrained heat formed by abscess.
Commentary on strategies
In particular, this formula suggests the herb combinations for eliminating pus from the Lung.
• It outlines the role of the blood circulation in the healing process of abscesses.
• It treats constrained heat by using Tao Ren to promote blood circulation and break up congealed blood.
11. Syndrome of heat in the Kidney and Bladder
Manifestations
Main symptoms
Night sweats, bone steaming, low-grade fever.
Secondary symptoms
Restlessness, anxiety, irritability, insomnia, chronic bleeding gums without pain, loss of teeth, spermatorrhea, turbid, scanty and dark urine, difficult and painful urination.
Tongue
Red with a yellow coating or without coating.
Pulse
Rapid.
Associated disorders in western medicine
Urinary tract infection, menopause syndrome, hyperthyroidism and chronic periodontitis.
Analysis of the syndrome
The Kidney is an organ that stores the essence and is believed never to have had a real excess syndrome during pathogenic processes. However, sometimes the empty-heat in the Kidney can be very strong and may further consume the essence and Yin of the Kidney.
• Yin deficiency with excess fire and empty-fire may cause night sweats, bone steaming, low-grade fever, restlessness, anxiety, irritability, insomnia, bleeding gums and spermatorrhea.
• Although the Bladder stores the urine, the Kidney controls the opening and closing of the Bladder. If heat invades the Lower-Jiao, consumes the Yin and fluid, and obstructs the Qi, turbid and scanty urine, and difficult and painful urination may appear.
Treatment principle: Reduce heat and nourish the Yin of the Kidney
Structure of the formula and selection of herbs
Chief: Clear heat and nourish the Yin of the Kidney
Zhi Mu ( Anemarrhenae rhizoma) and Xuan Shen ( Scrophulariae radix)
Zhi Mu and Xuan Shen are bitter and cold. Both enter the Kidney meridian. They can reduce the heat and nourish the Yin of the Kidney. They can be used as chief herbs in a formula to reduce the empty-heat of the Kidney. Moreover, since Zhi Mu enters the Lung meridian and Xuan Shen can ascend the Kidney-water to reduce the fire of the Heart, Zhi Mu can be used in conditions where thirst and fever exist, and Xuan Shen can be used in cases of restlessness and insomnia.
Huang Bai ( Phellodendri cortex)
Huang Bai is bitter and cold, and enters the Kidney meridian. It is able to reduce the empty-fire of the Kidney and is used to treat spermatorrhea, hot flushes and night sweats. It can also clear the damp-heat in the Lower-Jiao and can treat turbid and scanty urine, and difficult and painful urination.
Deputy: Nourish the body fluids, clear heat in the related organ and cool the blood
Sheng Di Huang ( Rehmanniae radix), Tian Men Dong ( Asparagi radix) and Nu Zhen Zi ( Ligustri lucidi fructus)
These three herbs are bitter, cold and sweet, and all enter the Kidney meridian. They serve as deputies to nourish the Yin and clear the heat of the Kidney. They can be used separately or together, depending on the degree of Yin deficiency.
Sheng Di Huang ( Rehmanniae radix), Mu Dan Pi ( Moutan cortex) and Xuan Shen ( Scrophulariae radix)
These three herbs are cold in temperature and they enter the blood. They can cool the blood and stop bleeding, and can be used in bleeding conditions such as heavy menstruation and blood in the urine.
Assistant: Regulate the Qi and recover the function of the involved organs
Ku Shen ( Sophorae flavescentis radix) and Ze Xie ( Alismatis rhizoma)
These two herbs are cold in temperature and enter the Kidney meridian. They can reduce the damp-heat from the Lower-Jiao and treat turbid, scanty and dark urine, and difficult and painful urination. As they have a downward-moving tendency, they can descend fire and the Qi. Moreover, Ku Shen is able to dry damp-heat and can be used orally or topically to treat foul vaginal discharge and itch in the genital region, such as in vaginitis. Ze Xie can reduce dampness by promoting urination and can also be used for edema in the legs.
Envoy: Harmonize herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao, as in the other conditions of internal heat syndrome, can be used in the formula to harmonize and moderate the functions of herbs and to protect the Stomach. However, in a damp-heat syndrome of the Lower-Jiao, Zhi Gan Cao – which has a tendency to retain dampness because of its sweet nature – should be used with caution.
Examples of classical formulas
Dang Gui Liu Huang Tang (Tangkuei and Six Yellow Decoction) 
Source: Lan Shi Mi Cang 
Composition
Dang Gui ( Angelicae sinensis radix) 12 g
Sheng Di Huang ( Rehmanniae radix) 12 g
Shu Di Huang ( Rehmanniae radix praeparata) 12 g
Huang Qin ( Scutellariae radix) 12 g
Huang Lian ( Coptidis rhizoma) 12 g
Huang Bai ( Phellodendri cortex) 12 g
Huang Qi ( Astragali radix) 24 g
Analysis of the formula
This formula nourishes the Yin and reduces heat of the Kidney, and is used particularly to stop sweating caused by Yin deficiency with severe empty-heat. The severe empty-heat manifests as night sweats, a red face, dry lips, irritability, constipation, dark and scanty urine, a red tongue with a yellow coating and a rapid pulse.
In this formula:
• Dang Gui, Sheng Di Huang and Shu Di Huang are used as chief herbs to tonify blood and Yin in order to treat the cause of the empty-heat.
• Huang Bai, Huang Lian and Huang Qin serve as deputies. They are used to clear the heat in the Lower-, Middle- and Upper-Jiao respectively, so as to powerfully control the heat and prevent further Yin consumption.
• Huang Qi, as assistant, tonifies the Qi, which is injured by the heat. It strengthens the exterior and therefore stops sweating.
Commentary on strategies
• The composition is characterized by using two groups of herbs that nourish the Yin and reduce fire. These groups support each other in stopping the pathological change.
• Moreover, herbs that usually reduce excess fire, such as Huang Lian and Huang Qin, can be used to reduce the severe empty-heat when the heat is intense. However, they must be used in combination with Yin-tonifying herbs such as Sheng Di Huang and Shu Di Huang. These herbs should not be used long term in the process of reducing the intensive empty-heat.
• As soon as the heat is less strong, herbs that reduce the empty-heat and nourish the Yin should be used, such as Zhi Mu ( Anemarrhenae rhizoma), and Han Lian Cao ( Ecliptae herba).
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| Figure 3.2 •. |
| Pathology of heat at the Qi level. |
