Chapter Eighteen. Syndrome of disharmony and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that treat some specific bodily disorders using the method of harmonizing.
Formulas that harmonize are mainly used to treat disharmony between internal organs, disharmony between Qi and blood, and syndromes characterized by the coexistence of heat and cold, or by the coexistence of deficiency and excess. By adopting the approach of harmonizing the involved aspects, further pathological development can be prevented. Some of the syndromes and classical formulas presented here have already been introduced in other chapters, but it will become apparent that the treatment methods and strategies adopted in these formulas can be viewed from other perspectives and inspire the creation of new formulas.
1. Syndrome of disharmony between the Liver and Spleen (Stomach and Large Intestine)
Manifestations
Main symptoms
Hypochondriac pain and distension, fullness in the chest, stomach and abdomen, irritability, depression and frustration, dream-disturbed sleep, irregular menstruation, a bitter taste in the mouth, dry mouth and throat, headache, vertigo, fatigue, reduced appetite, nausea, vomiting and diarrhea, cold hands and fullness in the chest when subject to strong emotional disturbance.
Tongue
Pale or pink, with a thin white coating.
Pulse
Wiry and deficient.
Associated disorders in western medicine
Acute and chronic gastroenteritis, hyperchlorhydria, prolapsed stomach, dilatation of the stomach, peptic and duodenal ulcers, stress-related belching and vomiting, irritable bowel syndrome, allergies, hepatitis, cholecystitis, and the side effects of some medicines.
Analysis of the syndrome
This syndrome is generally referred to as disharmony between the Liver and Spleen. In fact, it can be divided into several sub-syndromes besides disharmony between the Liver and Spleen, such as disharmony between the Liver and Stomach, and disharmony between the Liver and Large Intestine. Since the Stomach and Large Intestine are directly linked to the transportation function of the Spleen, and both belong to Earth in the Five-Element theory, the Liver often attacks these organs if it overacts on the Spleen. Hence they are often considered and discussed as one syndrome under the name of disharmony between the Liver and Spleen.
The Liver is an important organ in human physiology. The free flow of Liver-Qi drives the functions of the internal organs. One of these is the Spleen’s function of transportation and transformation. The proper flow of Liver-Qi depends on an adequate supply of Liver-blood, which is generated from the food essence and is transformed by the Spleen. These physiological features mean that there is a special relationship between the Liver and the Spleen. In pathological conditions, any of these three factors (Liver-Qi stagnation, Liver-blood deficiency or Spleen-Qi deficiency) can impact on, or be influenced by, the other two. This may lead to disharmony between the organs and cause the following manifestations:
• If Liver-Qi stagnation is the causative factor, there is obvious hypochondriac pain and distension, and fullness in the chest, stomach and abdomen arises because the Liver and Gall Bladder meridians spread through the hypochondriac region, and the Qi of these organs moves through the pathways of the San Jiao.
• When Liver-Qi is stagnant, patients get angry easily, and are prone to irritability, depression and frustration. They tend to have dream-disturbed sleep, and female patients may have irregular menstruation. Furthermore, the Liver-Qi can easily generate heat if it stagnates, even if only for a very short time.
• Liver-fire gives rise to a bitter taste in the mouth and dry mouth and throat. In most cases, the stagnation of Liver-Qi has a clear causative factor, usually stress.
• If there is obvious Liver-Qi stagnation but the cause is unclear, it is most likely caused by Liver-blood deficiency. In that situation, the Liver-blood is too weak to nourish the Liver, so the Qi moves slowly and tends to become stagnant. The syndrome of Liver-blood deficiency manifests as dizziness, vertigo, headache, migraine, tiredness, pale complexion, brittle nails and hair, irregular menstruation, irritability and mood swings.
• In the case of Spleen-Qi deficiency, the Qi is unable to ascend properly to the head, and patients often have chronic headaches, vertigo, fatigue and poor appetite.
• As soon as the Spleen becomes weak, it becomes vulnerable to attack from the Liver. When the Liver-Qi overacts on the Spleen, the Qi is blocked in the Middle-Jiao. The Stomach-Qi cannot descend, thus fullness in the stomach, nausea and vomiting may occur; the Spleen-Qi is unable to ascend, thus giving rise to diarrhea.
• When there is strong emotional disturbance, the Qi is obstructed in the chest, so it cannot spread and is unable to reach the extremities, resulting in cold hands and fullness of the chest.
• Liver-Qi stagnation does not manifest in a distinct tongue sign; however, if heat is generated, a red border can be observed on the tongue.
• If Liver-Qi overacts on the Spleen and Stomach, a thick coating can be found on the tongue, showing that the digestion is impaired.
• When blood is deficient, the tongue is pale or a delicate pink color. If there is Spleen-Qi deficiency, the tongue is pale with teeth marks.
• The typical Liver-Qi stagnation pulse is wiry. If there is also blood deficiency, a thready pulse can be felt. If there is obvious Qi deficiency, the pulse can be weak, particularly in the Spleen position.
(See Figures 18.1 and 18.2 on page 378.)
Treatment principle: Harmonize the Liver and Spleen; regulate the Qi
Herb selection principles and formula composition strategies
• In most cases, herbs that can spread the Liver-Qi and reduce mental and physical tension are selected, along with herbs that nourish the Liver-blood.
• Herbs that strengthen the Spleen are often selected, first to provide a blood supply so as to maintain the proper function of the Liver, second to allow the Spleen to resist attack by the Liver-Qi, and third to treat Spleen-Qi deficiency.
• Pungent-warm herbs that can ascend the Qi and bitter-cold herbs that can descend the Qi are often used together to harmonize these involved organs and reduce tension.
Structure of the formula and selection of herbs
Chief and Deputy: Harmonize the Liver and Spleen; regulate the Qi in the Middle-Jiao
Note
Since each of the three factors – Liver-Qi stagnation, Liver blood deficiency and Spleen-Qi deficiency – can be a causative factor as well as a consequence of the others, the chief is used to treat the direct cause and the deputies treat the developed conditions and the consequences. Thus, the chief and the deputies can be selected from the following three groups of herbs.
Xiang Fu ( Cyperi rhizoma), Chai Hu ( Bupleuri radix), Qing Pi ( Citri reticulatae viride pericarpium) and Mu Xiang ( Aucklandiae radix)**
These herbs are often selected to spread the Liver-Qi.
Chai Hu is another commonly used herb to regulate the Liver-Qi and is also a gentle herb. Unlike Xiang Fu, it has the function of dispersing and ascending the Liver-Qi rather than promoting its circulation. It is particularly suitable for use as chief in formulas to spread constrained Liver-Qi that is directly caused by stress, depression and frustration. Since the tendency of its action is upwards, it should be used with caution in syndromes of ascending of Qi, fire or Yang of the Liver.
Qing Pi is warm and bitter, and enters the Liver, Gall Bladder and Spleen meridians. It can break up the Qi stagnation and effectively promote the free flow of Liver-Qi and alleviate pain. It is often selected in a formula to treat distending pain in the chest, breasts and hypochondriac region. Because its action is strong, it may injure the Qi and Yin, and therefore it is used only for a short period of time and mainly in excess conditions.
Mu Xiang is pungent, bitter, warm and aromatic, and enters the Gall Bladder, Spleen and Large Intestine meridians. It can strongly and quickly activate Qi movement, and can especially regulate Qi of the Liver and Large Intestine and alleviate pain. It also strengthens the Spleen and promotes the digestion. It is especially effective in treating disorders where the Liver-Qi overacts on the Spleen, causing stomachache, abdominal pain and distension, diarrhea, poor appetite and poor digestion. As this herb is quite warm and pungent, and is strong in action, its dosage should be controlled carefully.
Dang Gui ( Angelicae sinensis radix) and Bai Shao Yao ( Paeoniae radix lactiflora)
These two herbs are often used to tonify the blood. Dang Gui is sweet, pungent and warm, and enters the Heart, Liver and Spleen meridians. It can tonify the blood, warm the blood and promote the blood circulation. Bai Shao Yao is bitter, sour and cold, and enters the Liver and Spleen meridians. It nourishes the Liver-Yin, tonifies the blood and stabilizes the blood circulation. Since Bai Shao Yao is able to soften the Liver and relax the tendons, it can reduce the aggression of the Liver. These two herbs tonify the Yang and Yin aspects of the blood and are therefore very often used together as one unit to nourish the blood, soften the Liver and keep the Liver-Qi moving steadily.
Ren Shen ( Ginseng radix), Bai Zhu ( Atractylodis macrocephalae rhizoma) and Fu Ling ( Poria)
These herbs are often selected to strengthen the Spleen.
Ren Shen and Bai Zhu are sweet and warm, and Fu Ling is sweet, neutral and bland. They all enter the Spleen meridian. They can directly tonify the Spleen and are selected as chief in the formula when the disharmony is caused directly by chronic Spleen deficiency. Moreover, they can also be used as deputies as they generate the Qi and blood, and can maintain the proper function of the Liver. In addition, they strengthen the Spleen in order to stimulate its resistance at the same time that the Liver-Qi is attacking the Spleen.
Assistant: Regulate the Liver-Qi, strengthen the Spleen, clear heat and remove phlegm in the Middle-Jiao
Xiang Yuan ( Citri fructus), Fo Shou ( Citri sarcodactylis fructus) and Mei Gui Hua ( Rosae flos)
These three herbs are often used in formulas to treat the syndrome of disharmony between the Liver and Stomach. Xiang Yuan and Fo Shou enter the Liver, Spleen and Stomach meridians. They are bitter, sour and slightly warm. Both are very effective in promoting the Liver-Qi movement and treating hypochondriac pain, distension and depression. Moreover, they are particularly effective in the condition where the stagnant Liver-Qi disturbs the Stomach and leads to distension in the gastric and hypochondriac regions. They can soothe the Stomach-Qi so as to improve appetite and stop vomiting and belching.
Mei Gui Hua has the function of harmonizing the Qi in the Liver and Stomach, and treats the syndrome of Liver-Qi attacking the Spleen and Stomach. As well as having functions similar to those of Xiang Yuan and Fo Shou, this herb can also promote the blood circulation and is an appropriate herb to treat disorders due to Qi and blood stagnation, such as irregular menstruation and dysmenorrhea.
Zhi Gan Cao ( Glycyrrhizae radix preparata) and Bai Shao Yao ( Paeoniae radix lactiflora)
Zhi Gan Cao is sweet and warm, and primarily enters the Spleen meridian. It can both tonify and moderate the movement of the Qi. It is often used with herbs that nourish the Yin such as Bai Shao Yao to strongly soften the Liver and relax the tendons. It is often used to protect the Stomach in the condition of Liver attacking the Stomach.
Bai Shao Yao is the most commonly used herb to soften the Liver. It is sour, bitter and slightly cold. It is able to nourish the Yin and blood of the Liver, and its cold and bitter nature can reduce heat, which is caused by deficiency of blood and stagnation of the Liver-Qi. It is often used in a formula to treat Liver-Qi stagnation, which is caused by Yin and blood deficiency. Besides the common symptoms of Qi stagnation, a thready and wiry pulse is the indication for using this herb in the formula. Moreover, Bai Shao Yao is also often used as corrective assistant. In the treatment, since the herbs that stimulate Qi may injure the blood and cause further stagnation of the Qi, it is necessary to nourish the blood in order to spread the Liver-Qi.
Jing Jie ( Schizonepetae herba) and Bo He ( Menthae herba)
Jing Jie and Bo He have a pungent taste, and enter the Liver meridian. They possess a light and subtle dispersing ability and can disperse the constrained Liver-Qi. They are selected as assistants in formulas to enhance the function of the chief in spreading the Liver-Qi and treating excess and deficiency conditions where Liver-Qi stagnation is involved.
Fang Feng ( Saposhnikoviae radix), Chen Pi ( Citri reticulatae pericarpium) and Zhi Shi ( Aurantii fructus immaturus)
These three herbs all enter the Spleen meridian. They can regulate the Spleen-Qi and Stomach-Qi. They are often selected as assistants in formulas to treat disharmony between the Liver and Spleen. Fang Feng enters the Liver and Spleen meridians, can effectively disperse Qi stagnation and relieve cramp and distension when the Liver attacks the Spleen. Since it ascends and spreads the Spleen-Qi, it can treat borborygmi and diarrhea. Chen Pi can promote Qi movement in the Stomach, reduce the sensation of fullness in the Stomach and improve appetite. Zhi Shi can descend the Qi in the intestines and reduce pain and distension in the abdomen.
Zhi Zi ( Gardeniae fructus) and Mu Dan Pi ( Moutan cortex)
When stagnant Liver-Qi generates heat and the heat disturbs the blood, these two herbs can be used in the formula.
Zhi Zi is cold and enters the San Jiao meridian. It can drain the excess heat from the Liver and the San Jiao passage, and leach out the heat by promoting urination. Mu Dan Pi is cold in nature and enters the blood level of the Liver meridian. It can cool the blood, promote the blood circulation and thus moderate the Qi movement. Its pungent taste can also disperse the stagnation of blood.
Qing Hao ( Artemisiae annuae herba) and Zhu Ru ( Bambusae caulis in taeniam)
These two herbs are cold in nature and can be used in formulas in conditions where damp-heat or phlegm-heat is generated in the Middle-Jiao.
Qing Hao is aromatic and enters the Liver and Gall Bladder meridians. It can disperse dampness and heat, spread Liver-Qi and is often used in damp-heat obstruction in the Liver and Gall Bladder. The manifestations are chills, fever, reduced appetite, nausea, and a sticky and bitter taste in the mouth.
Zhu Ru enters the Stomach and Gall Bladder meridians. It can soothe the Stomach-Qi and eliminate phlegm-heat. It treats nausea, vomiting, fullness in the Stomach and irritability.
Sheng Jiang ( Zingiberis rhizoma recens) and Da Zao ( Jujubae fructus)
Sheng Jiang is pungent and slightly warm, and enters the Stomach and Spleen meridians. It can soothe the Stomach-Qi, subtly disperse accumulation of dampness, fluid and phlegm in the Stomach, and can therefore promote digestion. Da Zao is sweet and warm, and can tonify the Qi and blood. These two herbs are often selected as assistants in the formula as a pair of herbs to gently strengthen the function of the Spleen and Stomach.
Examples of classical formulas
Xiao Yao San (Rambling Powder) 
Source: Tai Pi Hui Min He Ji Ju Fang 
Composition
Chai Hu ( Bupleuri radix) 6–9 g
Dang Gui ( Angelicae sinensis radix) 9 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Bai Zhu ( Atractylodis macrocephalae rhizoma) 9 g
Fu Ling ( Poria) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Wei Sheng Jiang (roasted Zingiberis rhizoma recens) 6 g
Bo He ( Menthae herba) 3 g
Analysis of the formula
This formula is able to harmonize the Liver and Spleen. It is used for treating Liver-Qi stagnation, Liver-blood deficiency and Spleen-Qi deficiency. The Liver overacts on the Spleen. The manifestations are hypochondriac pain, headache, vertigo, a bitter taste in the mouth, dry mouth and throat, fatigue and reduced appetite. In some cases, there may be alternating fever and chills, irregular menstruation, or breast distension and pain. The tongue color is often pale or pink with a thin white coating and the pulse is wiry and deficient.
In this syndrome, each of the three factors (Liver-Qi stagnation, Liver-blood deficiency and Spleen-Qi deficiency) can influence, or be influenced by, the other two. This may lead to disharmony between the functions of the Liver and Spleen and cause related manifestations.
In this formula, there are three groups of herbs that treat the pathological changes from the three factors involved.
• The first group is used to directly spread the Liver-Qi which can then further promote blood circulation and boost the function of the Spleen. This strategy is represented by the selection of Chai Hu and is enhanced by Bo He.
• The second group serves to tonify the Liver-blood and therefore to soften the Liver and promote its Qi movement; it is represented by Dang Gui and Bai Shao Yao.
• The third group is selected to tonify the Spleen-Qi so as to produce enough blood to support the function of the Liver. This strategy is carried out by using Bai Zhu and Fu Ling and is further enhanced by Sheng Jiang and Zhi Gan Cao.
With regard to the structure of this formula, Liver-Qi stagnation predominates and Chai Hu is used as the chief herb. If blood deficiency is obvious and is the cause of the Liver-Qi stagnation, Dang Gui and Bai Shao should be used as chief herbs. When the Spleen-Qi has been very weak for a long period of time, and has led to blood deficiency and Liver-Qi stagnation, herbs that tonify the Spleen should be used as chief herbs.
Commentary on strategies
This formula is characterized by harmonizing the functions of the Liver and Spleen through the understanding of the relationship between the Qi and blood, the material aspect and the functioning aspect of the Liver, and the relationship of the Liver and Spleen. It is a gentle and well-organized formula. It is not only a good example for study, but also a good formula that can be used for a long period of time.
Si Ni San (Frigid Extremities Powder) 
Source: Shang Han Lun 
Composition
Chai Hu ( Bupleuri radix) 6–9 g
Zhi Shi ( Aurantii fructus immaturus) 9–12 g
Bai Shao Yao ( Paeoniae radix lactiflora) 12–24 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6–9 g
Analysis of the formula
This formula can spread constrained Liver-Qi, soften the Liver and regulate the function of the Spleen. It is used for treating an acute excess condition where the Liver-Qi is stagnant and overacts on the Spleen. When strong emotions disturb the Qi movement, the Liver-Qi is obstructed and unable to spread throughout the entire body, especially to the extremities. This leads to cold fingers and toes, stiff and painful muscles, irritability and fullness in the chest. When Liver-Qi is severely stagnant, it can overact on the Spleen and Stomach, causing fullness and pain in the epigastrium and abdomen, and even severe diarrhea. In this syndrome, patients often show a red tongue with a yellow coating, and have a wiry pulse.
In this formula:
• Chai Hu is used as chief to spread the Liver-Qi directly.
Buy Membership for Complementary Medicine Category to continue reading. Learn more here
