CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies of the composition of formulas that have the function of tonifying and nourishing the body. They are used to treat different kinds of deficiency syndromes.
The formulas that tonify are arranged following these four aspects for the convenience of syndrome differentiation and treatment. The compositions of formulas are followed by different syndromes in each category and are discussed in detail. In practice, especially when treating chronic deficiency syndromes, an integrated treatment to tonify more substances and organs is required. A formula should be composed with thoughtfulness, yet following the principles and strategies demonstrated separately in this chapter.
CAUTIONS
1. Use in deficiency conditions only:
Formulas that tonify are, in general, applied for treating deficiency syndrome. They should not be used in conditions where substantial excess pathological products are present, such as phlegm, food and water accumulation, and stagnation of Qi and blood. This is because many tonifying herbs in the formulas have a rich and cloying nature and may retain material pathological products in the body. For the same reason, they are not suitable for conditions where exogenous pathogenic factors exist. However, in many cases, the deficiency syndromes coexist with excess pathological factors, or the internal disorders coexist with external factors. Quite often the factor of deficiency plays a causative role in the whole pathological process, thus the formulas that tonify can be used with herbs that eliminate the excess and exogenous pathogenic factors.
2. Protect the function of the Spleen and promote Qi movement in the Middle-Jiao:
Compared with formulas in the other chapters, formulas that tonify contain many tonifying herbs. These herbs have a sweet and cloying nature and are not easily digested, especially in patients with deficiency of the Spleen and Stomach, in elderly people and in children. The herbs that stimulate Qi and the herbs that promote digestion are almost always recommended in composing these formulas.
3. Plan an appropriate treatment course and diet:
An appropriate treatment course with an appropriate diet should also be taken in consideration in practice. Treatment of chronic deficiency syndromes should take place in stages. Generally speaking, it is better to start tonifying treatment in the winter rather than in the summer because winter is the time of storing and the digestive capability is stronger than in the summer. Another time to start treatment is following the changes of the Yin and Yang in nature. In cases of Yin deficiency, treatment should cover the spring and summer; in cases of Yang deficiency, treatment should start in the autumn and end after winter. At the same time, diets that can tonify and protect the Spleen and Stomach are also recommended to patients.
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13. Syndrome of Heart-Yang deficiency
Manifestations
Main symptoms
1. Palpitations, shortness of breath, which is often worse in winter and on exertion, pale complexion, cold extremities, stuffiness in the chest.
2. Chest Bi syndrome: Severe chest pain, breathlessness, cold sweats, extremely cold limbs and very deep and weak pulse.
3. Heart-Yang collapse: Loss of consciousness, cold sweats, extremely cold limbs and a very deep and weak pulse.
Secondary symptoms
Edema, shortness of breath, dizziness, nausea, vomiting or coughing out clear, thin, cold fluid, small amount of urine.
Tongue
Pale, dull color with teeth marks, and a white and moist coating.
Pulse
Deep, weak and irregular, or deep, slow and wiry.
Associated disorders in western medicine
1. Rheumatic heart disease, pulmonary heart disease, pulmonary emphysema, anemia, nephritis, drugs that inhibit heartbeat and reduce blood pressure, poor nutrition or having a low calorie diet.
2. Chest Bi syndrome: Acute myocardial infarction, angina pectoris.
3. Heart-Yang collapse: Acute myocardial infarction, heavy bleeding, dropping of blood pressure in shock and before death in terminal disease.
Analysis of the syndrome
The Heart is a fire organ. The Heart-Yang is very important in promoting the blood circulation and spreading the warmth in the body. The Heart-Yang can be injured directly by Yang and blood obstruction, such as in chest Bi syndrome or in an accident where there is heavy bleeding. This syndrome also arises in chronic conditions, e.g. chronic Kidney-Yang deficiency and Spleen-Yang deficiency.
• When the Heart-Yang is deficient, it fails to spread the warmth in the body, promote the Qi movement in the chest or circulate the blood, and therefore cold extremities, stuffiness in the chest and severe chest pain, cold limbs and a very deep and weak pulse present.
Two common syndromes that are referred to as the cold water affects the Heart and the cold water attacks the Lung mainly cause the secondary symptoms. These may occur if there is Heart-Yang and Kidney-Yang deficiency, or Heart-Yang and Spleen-Yang deficiency.
• When the Heart-Yang is too weak in the Upper-Jiao, the cold water may move upward from the Lower- or Middle-Jiao and attack the Heart and the Lung; thus shortness of breath, dizziness, vomiting or coughing out of clear, thin, cold fluid, and edema appear.
Treatment principle: Tonify the Heart-Yang, expel the coldness in the chest and promote blood circulation
Herb selection principles and formula composition strategies
• First, sweet and warm herbs that enter the Heart meridian and are able to tonify and stimulate the Heart-Yang are selected.
• Second, pungent and warm herbs to scatter cold in the Upper-Jiao, spread the warmth in the body and accelerate the water metabolism are used.
• Third, sweet and warm herbs that can tonify the Spleen-Qi, tonify blood and promote blood circulation, and accelerate water metabolism are used.
CAUTIONS
1. Avoid large dosage:
Herbs that are pungent and hot, can stimulate the Yang and Qi but consume the Qi and scatter the Yang should not be used in large dosage.
2. Protect the Heart:
Harsh herbs that place an extra burden on a weak heart should not be used.
3. Caution in bleeding conditions:
Pungent and hot herbs should not be used alone in a bleeding condition or in a syndrome where Yin deficiency coexists with Yang deficiency.
Structure of the formula and selection of herbs
Chief: Tonify the Heart-Yang
Gui Zhi ( Cinnamomi cassiae ramulus) and Zhi Gan Cao ( Glycyrrhizae radix preparata)
Gui Zhi is pungent, sweet and warm, and enters the Heart, Lung and Bladder meridians. It can warm and stimulate the Yang and Qi of the Heart, spreads the Yang and Qi, particularly in the chest, and treats chest pain due to Yang deficiency of the Heart. It can promote blood circulation and treat cold limbs and a weak pulse. In addition, as it is able to disperse the accumulation of cold fluid, which is the result of Spleen-Yang or Kidney-Yang deficiency, it is often used in the syndrome of cold water attacking the Heart or the Lung. Since its pungent property is stronger than its sweet taste, its function is more to spread the Yang than to tonify the Yang. Thus, it is often used with Zhi Gan Cao to enhance tonification.
Zhi Gan Cao is sweet and neutral. It is considered to enter every regular meridian, but particularly the Spleen meridian. According to the concept that the combinations of sweet, warm and pungent properties may tonify and strengthen the Yang, it is often used with pungent and warm herbs to tonify the Heart-Yang. Its sweet taste brings moderating and harmonizing functions. It can relieve chest pain, palpitations, restlessness and shortness of breath. It also relieves depression, anxiousness and anxiety due to deficiency of the Heart.
Deputy: Stimulate the Yang, regulate the Qi and blood in the chest
Xie Bai ( Allii macrostemi bulbus)
Xie Bai is pungent, bitter and warm, and enters the Lung, Stomach and Large Intestine meridians. Since pungent moves upwards and outwards, and bitter moves downwards, this herb has an intense strength of dispersing the cold accumulation in the chest, warming the Yang and stimulating the Yang and Qi. It is an important herb to treat chest Bi syndrome as it can open up the obstruction of cold and allow the Yang, Qi and blood to move freely.
Tan Xiang ( Santali albi lignum)
Tan Xiang is pungent and warm, and enters the Spleen, Stomach and Lung meridians. It can disperse cold, warm the Upper- and Middle-Jiao and regulate the Qi movement. It is particularly effective in relieving pain due to Qi and cold obstruction. It focuses on the diaphragm, relieves the cramp and eases the diaphragm. It can be used as deputy in formulas that treat Heart-Yang deficiency and Qi obstruction with symptoms of chest pain and breathlessness.
Chuan Xiong ( Chuanxiong rhizoma)
Chuan Xiong is pungent and warm, and enters the Liver, Gall Bladder and Pericardium meridians. It has an intense dispersing action, can stimulate the blood and Qi, open up the obstruction and stop pain. It can be used as deputy to stimulate the Heart-Yang and relieve chest pain due to cold and blood obstruction.
Assistant: Strengthen the Qi and blood, calm the mind and eliminate the accumulated water
Huang Qi ( Astragali radix) and Dang Gui ( Angelicae sinensis radix)
Huang Qi and Dang Gui are sweet and warm; the former particularly strengthens the Spleen-Qi and the latter is able to tonify the blood. They can tonify the Heart-Yang indirectly through strengthening the source of Qi and blood of the Heart and strengthening the material base of the Heart-Yang.
Long Yan Rou ( Longanae arillus)
Lou Yan Rou is a sweet fruit. It enters the Heart and Spleen meridians and can gently tonify the Spleen-Qi, the Heart-Qi and the blood. It can calm the mind and treat restlessness, anxiety and insomnia. It is suitable for use in a chronic condition of Heart-Yang deficiency with restlessness and palpitations.
Long Gu ( Mastodi fossilium ossis)
Long Gu is a mineral substance and is neutral. It can effectively sedate the Heart-spirit and calm the mind. In the condition of Heart-Yang deficiency, it can be used as an assistant in the formula to settle the mind and treat restlessness, palpitations and anxiety due to Yang deficiency.
Sheng Jiang ( Zingiberis rhizoma recens) and Fu Ling ( Poria)
Sheng Jiang and Fu Ling can be used in the syndrome of cold water attacking the Heart and Lung. If patients vomit clear and thin fluid, Sheng Jiang can be applied as it disperses the coldness and water accumulation in the Stomach and can soothe the Stomach-Qi as well. If patients feel dizzy and have a restless sensation in the area above the umbilicus, Fu Ling can be applied to eliminate the dampness from the Middle- and Lower-Jiao and promote urination to prevent cold water attacking the Heart.
Common accompanying symptoms and treatment
• Stagnation of the blood: add Tao Ren ( Persicae semen), Hong Hua ( Carthami flos) and Su Mu ( Sappan lignum) to promote blood circulation.
• Heavy sweating: add Wu Wei Zi ( Schisandrae fructus) and Fu Xiao Mai ( Tritici fructus germinatus) to stabilize the fluid and add Mu Li ( Ostrea concha) to sedate the floating-Yang and reduce sweating.
Examples of classical formulas
Gui Zhi Gan Cao Long Gu Mu Li Tang (Cinnamon Twig, Licorice, Dragon Bone and Oyster Shell Decoction) 
Source: Shang Han Lun 
Composition
Gui Zhi ( Cinnamomi cassiae ramulus) 6 g
Gan Cao ( Glycyrrhizae radix) 12 g
Long Gu ( Mastodi fossilium ossis) 12 g
Mu Li ( Ostrea concha) 12 g
Analysis of the formula
This formula was devised by Dr Zhang Zhong Jing. It treats Heart-Yang deficiency and cold in the Upper-Jiao. The manifestations are palpitations, restlessness, anxiety, shortness of breath, cold limbs, a pale complexion, a pale tongue and a weak, restless pulse.
In the formula:
• Gui Zhi and Gan Cao can directly tonify the Heart-Yang. Gui Zhi is also able to spread the Yang and promote the blood circulation. As they treat the cause of the disorder directly, both are considered as chief herbs in the formula.
• Long Gu and Mu Li are mineral substances. They are heavy in nature and in their actions. They are able to descend the Qi and Yang, calm the mind, settle the Heart-shen and treat symptoms such as restlessness, anxiety, palpitations and shortness of breath directly. They are considered as assistants.
Commentary on strategies
This is a small formula but each of the substances has its specific function and has a strong action in the formula. They show the style of composition of formulas of Dr Zhang Zhong Jing as well as the experience of using herbs in his time.
Shen Fu Tang (Ginseng and Prepared Aconite Decoction) 
Source: Zhong Ti Lei Yao 
Composition
Ren Shen ( Ginseng radix) 9 g
Fu Zi ( Aconiti radix lateralis preparata)* 6 g
Analysis of the formula
This formula is used at the critical time of Yang collapse. Patients can gradually lose consciousness, have cold sweats, extremely cold limbs and a very deep and weak pulse. In this formula, two strong herbs are chosen.
• Fu Zi, a pungent and very hot herb, can strongly expel cold, stimulate and spread the Yang.
These two herbs enhance each other’s actions and focus on intensively tonifying and reviving the Yang. In this way, they can rescue patients from Yang collapse.
Commentary on strategies
This small formula shows the basic rules of treating Yang collapse.
• Although the sign of internal cold is obvious and to a severe degree, the warm and pungent herbs that stimulate the Yang should not be used in the first instance as they may scatter the Yang, which is already at a minimum.
• Ren Shen should be used first as it can strongly tonify and stabilize the Qi so as to hold the Yang.
• Since Fu Zi may scatter the Yang and may overstimulate the weak heart, the dosage of Ren Shen should be always larger than that of Fu Zi.
This formula is more for study than for clinical use. It should be used with caution and is better used with modification in clinical practice.
Ling Gui Zhu Gan Tang (Poria, Cinnamon Twig, Atractylodes Macrocephalae and Licorice Decoction) 
Source: Jin Kui Yao Lue
Composition
Fu Ling ( Poria) 12 g
Gui Zhi ( Cinnamomi cassiae ramulus) 9 g
Bai Zhu ( Atractylodis macrocephalae rhizoma) 6 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Analysis of the formula
This formula treats a syndrome that is referred to as cold water attacking the Heart and Lung. In this syndrome, the cold water is generated by Spleen-Yang deficiency, and the water is pushed upwards by the Stomach-Qi, which failed to move downwards, and disturbs the proper movement of the Qi in the Upper-Jiao. Patients may suffer from fullness in the chest and hypochondria, palpitations, shortness of breath, coughing up clear and watery phlegm, dizziness and vertigo. The tongue is flabby and pale with a white moist coating. The pulse is slippery and wiry.
In the formula:
• Fu Ling, as chief, can directly drain the water, dissolve dampness and fluid, and tonify the Spleen.
• Gui Zhi, as deputy, can stimulate the Yang, warm the water and accelerate the process where the water evaporates into Qi, thus directly stimulating the process of dissolving the fluid and draining the water.
• Bai Zhu is another deputy. It can tonify the Spleen and dry the dampness, thereby reducing the formation of fluid.
• Zhi Gan Cao serves as assistant. It is used to protect the Yin as the herbs that drain the water may injure the Yin. It can also tonify the Spleen-Qi.
Commentary on strategies
Although this is a small formula, it shows different methods of eliminating the fluid in the condition of Spleen-Yang and Qi deficiency.
• Fu Ling is used to drain the accumulated water by promoting urination.
• Gui Zhi is used to warm and stimulate the Yang so as to accelerate water metabolism.
• Bai Zhu is used to tonify the Spleen and dry the dampness.
• The formula focuses on dissolving accumulated fluid, but the side effects of the warm and drying herbs are also considered; thus sweet Zhi Gan Cao is used to protect the Yin and tonify the Spleen-Qi.
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| Figure 5.1 •. |
| Qi from origin. |
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| Figure 5.2 •. |
| The nomination of Qi and functions. |
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| Figure 5.3 •. |
| Relationship between Heart-Qi and blood. Relationship between the Heart, Spleen and Lung. |
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| Figure 5.4 •. |
| Relationship between Qi and blood of the Liver; relationship between the Liver, Spleen and Kidney. |
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| Figure 5.5 •. |
| Relationship between Yin, Yang, Qi and essence of the Kidney. |
