Chapter Four. The internal cold syndrome and formula composition
CHAPTER CONTENTS
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that expel cold, warm the meridians and internal organs, and rescue the Yang from collapse. They are used for treating internal cold syndrome.
The internal cold syndrome
Manifestations
Main symptoms
1. Cold and severe pain of the limbs, cramp of the muscles, stiffness of the body.
2. Cramping pain of the abdomen, a preference for warm drinks, diarrhea or soft stool without a strong smell, distension of the abdomen and poor appetite.
3. Edema or frequent urination.
4. Impotence, infertility, aqueous-grainy diarrhea.
5. Yang collapse syndrome: Palpitations, shortness of breath, chest pain and a stifling sensation in the chest, shallow breathing and profuse sweating, pallid complexion, indifferent expression and slow reactions.
6. Floating-Yang syndrome: Flushed face, a floating red color that appears only on the cheeks, heavy sweating, weak and cold limbs, a pale or light purple tongue with a moist coating, and a weak and rootless pulse.
Secondary symptoms
Dysmenorrhea with cramping pain in the lateral sides of the lower abdomen, depression.
Tongue
Pale, purple or bluish color with a white coating.
Pulse
Deep, slow and weak.
Associated disorders in western medicine
Arthritis, chronic colitis, peptic ulcer, gastritis, enteritis, influenza, liver diseases, hypothyroidism, chronic nephritis, myocardial infarction, myocarditis, severe blood loss, trauma, severe dehydration and allergies.
Analysis of the syndrome
An internal cold syndrome develops under several conditions.
The exogenous pathogenic cold can directly cause internal cold syndrome. After exposure to cold, rain or snow, the exogenous pathogenic cold can invade the body through skin and subcutaneous tissue, and thereafter enter the meridians and internal organs.
• Cold has a contracting nature, can directly obstruct Qi movement and cause the typical symptom of cramping pain, which can be relieved by warmth.
• Cold obstructs the warm spreading of Yang, the movement of the Qi and the circulation of the blood. Patients therefore suffer from cold sensation, severe pain and cramp of the muscles, and stiffness of limbs, such as in a Bi syndrome caused by wind, cold and dampness.
Through inappropriate consumption of cold food and drink, the exogenous pathogenic cold can directly enter the Stomach and accumulate in the Middle-Jiao.
• When cold obstructs the Yang and Qi, patients may have acute cramping pain in the stomach or abdomen, and may have diarrhea.
The internal cold syndrome can be caused by Yang deficiency in different organs.
• Kidney-Yang deficiency is often seen in elderly people, people with a poor constitution and patients with chronic diseases. When the Kidney-Yang fails to accelerate water metabolism, edema or frequent urination may occur. When the Kidney-Yang and Qi are unable to warm the Lower-Jiao and maintain its function, impotence, infertility, dysmenorrhea and aqueous-grainy diarrhea may occur.
• Spleen-Yang deficiency often occurs in people with chronic disorders of digestion. When the Spleen-Yang is too weak to warm the internal organs, meridians and muscles, it causes a cold sensation and cramping pain of the abdomen and diarrhea. When the Qi in the Middle-Jiao is too weak, distension of the abdomen and poor appetite appear.
• Heart-Yang deficiency exists in people who have been under stress and emotional distress for a long period of time, or in patients who suffer from severe heart and lung diseases. When the Yang in the chest is too weak to promote the Qi movement and blood circulation, palpitations, shortness of breath and chest pain start.
(See Figure 4.1 on page 128.)
Syndrome of Yang collapse
The syndrome of Yang collapse is caused by serious disturbance of the balance among Yin, Yang, Qi and blood under the influence of pathogenic factors. When blood and Yin are suddenly weakened, or Qi and blood are suddenly obstructed, they fail to support the Yang and the Yang collapses.
• Since Heart-Yang and Kidney-Yang are the principal Yang of the body, Yang collapse means Heart-Yang collapse and Kidney-Yang collapse. In these severe and acute conditions, patients suffer from extremely cold extremities, a severe cold sensation that cannot be alleviated by warmth, chest pain with a stifling sensation and shallow breath.
• When the Qi is too weak to hold the Yang, heavy sweating may start.
• When the Heart-Qi is unable to support the Heart-shen, pallid complexion, indifferent expression and slow reactions are shown.
(See Figure 4.2 on page 128.)
Floating-Yang syndrome
Like the collapse of Yang, floating-Yang syndrome is a dangerous situation. It appears when the Kidney-Yang is extremely weak and the internal cold in the Lower-Jiao is at its maximum.
• When the cold forces the Yang to move upwards, the manifestations are flushed face, a floating red color that appears only on the cheeks and heavy sweating.
• The cold manifests as very weak and cold limbs, a pale or light purple tongue with a moist coating, and a weak and rootless pulse.
(See Figure 4.3 on page 128.)
Treatment principle: Warm the Yang of the Heart, Spleen and Kidney; expel cold; harmonize the Qi and blood
Herb selection principles and formula composition strategies
• First, herbs that are very pungent and hot, enter the Heart, Spleen and Kidney meridians, can disperse cold, warm the interior, relieve cramp, open up the meridians and promote Qi movement are selected.
• Second, herbs that are sweet and slightly warm, enter the Spleen and Kidney meridians, can tonify Qi of the internal organs and thereby gently promote the function of the Yang are selected.
• A small amount of sour and cold herbs should be selected to nourish the Yin and blood and generate the body fluids, as well as reduce the side effects of pungent and hot herbs.
• Herbs that regulate Qi and blood, can dry cold-dampness and eliminate it can be used.
• In the syndrome of Yang collapse, if the Yang is extremely weak and the internal cold exceeds its maximum, and the conflict between the cold pathogenic factor and the hot herbs is very severe, a small amount of cold herb, which follows the nature of the pathogenic cold, can be added. This herb serves as strategic assistant in the large amount of hot herbs used to reduce the conflict and is helpful in fulfilling the therapeutic effect.
CAUTIONS
1. Make a clear differentiation:
In many conditions, when the Qi is obstructed, cold sensation can also appear. When the Yin is too weak to nourish the tendons and muscles, cramp of limbs may also appear. Many patients with blood deficiency also have Yin deficiency with heat in the blood; they are often afraid of cold since the Qi is not strong. A clear and correct differentiation of the syndrome is therefore required at the outset.
2. Protect the Yin:
Many of the herbs in the formula that warm the interior are very pungent and hot, and can consume the Yin and body fluids if they are used for too long or in a large dosage. They may bring about side effects, such as dry mouth, throat and nasal passages, thirst, sore throat, constipation, itchy and dry skin, a burning sensation in the stomach and palpitations. Thus they should not be used long term or in large dosage, especially in patients with Yin and blood deficiency.
3. Caution in bleeding conditions and pregnancy:
In formulas that warm the interior, very pungent and hot herbs, which are able to stimulate the blood circulation, should not be used in bleeding conditions or in pregnancy.
Structure of the formula and selection of herbs
Chief: Directly stimulate the Yang or tonify the Yang, warm the internal organs and meridians and expel cold
These herbs are pungent and hot, and can directly scatter internal cold. They are used for treating excess internal cold syndrome. They can also stimulate the Yang of the internal organs and accelerate their functions so as to disperse the internal cold in both excess and deficiency conditions.
Gui Zhi ( Cinnamomi cassiae ramulus) and Xi Xin ( Asari herba)*
Gui Zhi and Xi Xin are able to warm meridians, promote Qi movement and blood circulation, and expel cold. They are selected in formulas to warm the meridians and treat Bi syndrome.
Gui Zhi is sweet and warm, and primarily enters the Heart meridian. It has an aromatic smell that gives this herb a thin pungent property, which makes it move quickly and lightly. It can particularly warm the blood, stimulate the Heart and promote the blood circulation; thus it can treat cold hands and feet, cramp of the muscles and pain due to cold obstruction of the blood circulation. In addition, Gui Zhi also enters the Lung and Bladder meridians, is able to expel wind and cold in the superficial region and can therefore treat exterior wind-cold syndrome.
Xi Xin is a very pungent and hot herb with an aromatic smell. It enters the Kidney meridian. Because of its strong aromatic smell, pungent taste and hot nature, it can easily penetrate into the deep regions of the body. It is very effective in eliminating cold and wind in these regions, such as the bones and tendons, as its ability to enter the Kidney meridian makes it easy to reach these structures. Xi Xin has the characteristic of seeking and eliminating wind, cold and dampness no matter if they are in the corners or chinks of the deep regions of the body. It is often used to stop pain when wind, cold and dampness stay in the deep regions of the body and the Kidney-Yang is weak. In such cases, patients not only have pain and a cold sensation in the affected joints, they also feel pain in the bones. They have difficulty with walking or cannot stand for long, have very stiff and painful tendons, especially in the lower body, feel cold in the extremities and are also afraid of cold. In winter or humid weather all the symptoms get worse.
The side effects of Xi Xin are the likelihood of injuring the Yin, blood and body fluids and it can weaken the Qi. As Xi Xin is a poisonous herb, the dosage should be controlled carefully.
Gao Liang Jiang ( Alpiniae officinari rhizoma), Wu Zhu Yu ( Evodiae fructus) and Ding Xiang ( Caryophylli flos)
All of these herbs are pungent and warm, and enter the Stomach meridian. They can warm the Stomach, expel cold and relieve cramping pain of the Stomach.
Gao Liang Jiang is hot and pungent, and its action is strong in warming the Stomach and alleviating pain. It can be used as chief in the formula to treat cramping pain in the upper abdomen, vomiting of clear fluid and a preference for warm drinks, such as in chronic gastritis and gastroduodenal ulcer.
Wu Zhu Yu is very pungent, bitter and hot, and enters the Liver, Spleen and Kidney meridians. It can warm the meridian, descend the Liver-Qi and treat ascending of the Liver-Qi due to excess cold in the Liver meridian. The indication is headache, particularly on the top of the head. In addition, Wu Zhu Yu can spread the Liver-Qi and can be used when the Liver-Qi attacks the Stomach, which manifests as cramping pain with a cold sensation in the Stomach and in the lateral sides of the lower abdomen, vomiting of clear fluid, and a wiry and slow pulse. This pattern can be found in disorders such as migraine, hypertension, peptic ulcer, chronic gastritis and dysmenorrhea.
Ding Xiang is warm and pungent, and enters the Stomach, Spleen, Lung and Kidney meridians. It can descend the Stomach-Qi, expel cold and reduce the cramping pain. It treats belching and hiccup caused by coldness in the Stomach.
Gan Jiang ( Zingiberis rhizoma), Xiao Hui Xiang ( Foeniculi fructus), Cao Dou Kou ( Alpiniae katsumadai semen) and Hua Jiao ( Zanthoxyli fructus)
All of these herbs are pungent and warm, and enter the Spleen meridian. They can expel cold and warm the Spleen-Yang. They can be used as chief herbs separately in formulas that treat coldness in the Middle-Jiao.
Gan Jiang is very pungent and hot, and enters the Spleen, Stomach, Heart and Lung meridians. It moves reasonable quickly and its action tendency remains in the Middle-Jiao. As it is particularly effective in warming the Spleen and Stomach, expelling cold and drying dampness, it can treat cramping and cold in the abdomen, vomiting and diarrhea due to internal cold in the Middle-Jiao.
Xiao Hui Xiang, Cao Dou Kou and Hua Jiao can all warm the Middle-Jiao and expel damp-cold. These three herbs are pungent and warm, and enter the Spleen and Stomach meridians. They are used to treat abdominal pain, distension, poor appetite, vomiting and diarrhea.
Xiao Hui Xiang is an aromatic herb. As it can disperse cold and promote Qi movement, it is able to alleviate pain and improve appetite.
Cao Dou Kou is also an aromatic herb. Unlike Xiao Hui Xiang, which promotes Qi movement, its strong point is to dry dampness and warm the Spleen. As a result, it can treat nausea, vomiting, diarrhea and poor appetite.
Hua Jiao has similar functions to Cao Dou Kou, but is much warmer, so its ability to dry dampness and disperse cold is stronger. Since this is a poisonous herb and it moves quickly in the Middle-Jiao, it is only used for acute excessive damp-cold syndrome for a short period of time, such as for severe cramping pain in the abdomen, frequent and urgent bowel movement and watery stools.
Fu Zi ( Aconiti radix lateralis preparata)*, Rou Gui ( Cinnamomi cassiae cortex), Xiao Hui Xiang ( Foeniculi fructus), Hua Jiao ( Zanthoxyli fructus), Ding Xiang ( Caryophylli flos) and Ai Ye ( Artemisiae argyi folium)
All of these herbs enter the Kidney meridian and are often used to treat internal cold syndrome by stimulating the Kidney-Yang.
Fu Zi and Rou Gui are the most commonly used herbs to warm the Lower-Jiao, the Kidney, and they can be used separately or together as chief herbs in formulas that warm the interior. However, there are a number of differences between these two herbs.
Fu Zi is a very pungent and hot herb. It enters the 12 regular meridians and moves quickly without any staying tendency. It can very quickly spread the Yang in the body. With these features, it treats internal cold syndrome. Since Fu Zi can spread the warmth quickly to the whole body through the 12 meridians, it can scatter cold and dampness in the body like the sun with the fog. This is the reason why Fu Zi is a very commonly used herb to treat Bi syndrome caused by cold, dampness and wind, as well as Yang deficiency of the body. Although Fu Zi enters the 12 meridians, it especially enters the Kidney meridian. It is vigorous in warming and stimulating the Kidney-Yang and promoting the functions of the internal organs so that it can rescue the Yang from collapse. Fu Zi is considered as the most important herb for treating Yang collapse. Although Fu Zi is an effective herb to stimulate the Yang, warm the interior and expel the cold, it is a very poisonous herb. The dosage and duration of the treatment should be carefully controlled.
Rou Gui is less pungent and hot than Fu Zi, but it has sweet taste and enters only the Kidney meridian. This makes Rou Gui especially effective to warm the Lower-Jiao, warm the Kidney and scatter the cold there. As it is sweet, it does not move very quickly. The strong point of this herb is that it spreads warmth in a steady and strong way and treats the coldness that it is impossible to scatter in a very short time, such as in disorders of impotence, infertility, amenorrhea and frequent urination. Rou Gui is also used for treating floating-Yang syndrome, is able to warm and tonify the fire of the vital gate and lead the floating fire back to its source. Moreover, Rou Gui warms the Kidney and the blood, scatters cold and stimulates blood circulation to alleviate pain, especially when the pain is in the abdomen, back and knees.
Xiao Hui Xiang can warm the Lower-Jiao because it enters the Kidney and Liver meridians. It can promote the Qi movement in the Lower-Jiao and treats abdominal pain, distension and cramp in the lateral sides of the lower abdomen.
Hua Jiao and Ding Xiang also enter the Lower-Jiao, are able to warm the Kidney-Yang and treat coldness in the lower back and abdomen, cold extremities, diarrhea and impotence.
Ai Ye is pungent and warm, and enters the Liver and Kidney meridians. Ai Ye is gentle in taste and temperature. It can warm the Liver, Kidney and Spleen meridians, and is especially suitable for regulating menstruation and can stop bleeding caused by cold in the Lower-Jiao. It can be used as chief herb in a formula to treat profuse menstrual bleeding and bleeding in pregnancy, as well as dysmenorrhea due to cold in the Lower-Jiao. It is considered an important herb for gynecological and obstetric disorders.
Ba Ji Tian ( Morindae radix) and Yin Yang Huo ( Epimedii herba)
Ba Ji Tian and Yin Yang Huo are warm, sweet and pungent, and enter the Kidney meridian. They can warm the Lower-Jiao and tonify rather than stimulate the Kidney-Yang. Therefore they can be used in chronic conditions for a longer period of time. They are used as chief herbs in formulas to treat cold sensation and weakness of the back and knees, infertility, frequent urination, loose stools, edema, impotence and tinnitus due to Kidney-Yang deficiency.
Deputy: Tonify the Qi in order to strengthen the Yang; tonify the Yang so as to enhance the ability of the chief herbs
Ren Shen ( Ginseng radix), Huang Qi ( Astragali radix) and Zhi Gan Cao ( Glycyrrhizae radix preparata)
Since Qi is a part of Yang, long-term deficiency of Qi may lead to deficiency of Yang. Herbs that tonify Qi are often used in formulas that strengthen the Yang and expel internal cold.
Ren Shen is sweet and slightly warm, and enters the Kidney, Spleen and Lung meridians. It is particularly able to tonify Yuan-Qi ( Source-Qi) and rescue the Yang from collapse. It is used as chief or deputy together with herbs that stimulate the Yang to treat critical conditions where the Qi is severely injured and the Yang has collapsed. Since Ren Shen can strongly tonify the Yuan-Qi, the principal Qi in the body, it can tonify the Qi of all the internal organs. It can enhance the ability of herbs that warm the interior. It can also treat the symptoms caused by Qi deficiency in the syndrome of Yang deficiency. For instance, it tonifies the Heart-Qi and calms the mind, thereby treating palpitations and restlessness. It tonifies the Spleen-Qi and promotes the digestion. Moreover, it promotes the generation of the blood, and treats fatigue and cold and weak limbs.
Huang Qi is sweet. It is warmer than Ren Shen in nature. Since it enters only the Lung and Spleen meridians, it has no function in tonifying the Yuan-Qi and is not used in critical conditions or in general Qi deficiency of all the internal organs. As its function focuses on the Spleen and Lung, it can strongly tonify and ascend the Spleen-Qi and promote digestion, thus enhancing the ability of the chief in a formula that warms the interior. In addition, since it can strongly tonify the Qi and ascend the Qi of the Spleen, warm the muscles and increase the strength of the muscles, it can treat the accompanying symptoms of a Yang deficiency condition, such as tiredness and a heavy sensation of the body and limbs. Huang Qi can tonify the Lung-Qi and stabilize the exterior, which are also often seen in a Yang deficiency condition.
Zhi Gan Cao is sweet and slightly warm, and enters all meridians. According to the concept that the combination of sweetness, warmth and pungency of herbs develops the ability to tonify the Yang, as deputy herb in formulas that warm the interior Zhi Gan Cao is often used in combination with pungent and warm herbs in order to tonify the Yang of the body. As sweetness may slow speed, reduce tension and alleviate the two or more conflicted aspects in a pathological development, this herb, as a deputy in the formula, can be used in critical conditions of Yang collapse. Moreover, the moderate nature of Zhi Gan Cao is also used effectively to treat cramp of muscles caused by the Liver-Qi overcontrolling the Spleen. A large dosage of Zhi Gan Cao is excellent to tonify Qi and harmonize the Qi movement. It can treat Heart-Qi deficiency where the Qi fails to promote blood circulation that brings about restlessness, palpitations, tightness in the chest and arrhythmia.
Du Zhong ( Eucomniae cortex), Gou Ji ( Cibotii rhizoma)**, Yi Zhi Ren ( Alpiniae oxyphyllae fructus) and Tu Si Zi ( Cuscutae semen)
These herbs are sweet and warm, and enter the Kidney meridian. They can tonify the Kidney-Yang and promote the functions of the Kidney. In formulas that warm the Lower-Jiao, these herbs can be used as deputies, particularly treating coldness due to deficiency of Yang in chronic conditions. They improve the condition of patients slowly but steadily.
Du Zhong and Gou Ji strengthen the back and benefit the joints. They can be used in chronic Bi syndrome due to wind, cold and dampness with Kidney-Yang deficiency, especially in elderly people.
Yi Zhi Ren and Tu Si Zi can tonify the Kidney-Yang as well as the Kidney-essence, and can be used for frequent urination, infertility and impotence due to Kidney-Yang deficiency.
Dang Gui ( Angelicae sinensis radix) and Pao Sheng Jiang (quick-fried Zingiberis rhizoma recens)
Dang Gui is pungent, sweet and warm, and enters the Heart, Liver and Spleen meridians. It can tonify the blood, warm the blood and promote blood circulation. As its function is effective and gentle, it can be used as deputy in formulas that warm the interior, especially when the cold is in the blood and slows up the circulation, such as in dysmenorrhea, chest pain, cold extremities and Bi syndrome due to cold in the blood.
Pao Sheng Jiang is bitter and warm, and enters the Middle-Jiao and the Spleen meridian. It particularly warms the Middle-Jiao and stops bleeding caused by Spleen-Yang deficiency, such as in peptic ulcer, chronic colitis and dysentery. It can also be selected as deputy in formulas that warm the Middle-Jiao.
Assistant: Promote the movement of Qi, eliminate cold-dampness; serve as strategic assistant in treating the syndrome of Yang collapse; moderate the harsh herbs and protect the Yin
Wu Yao ( Linderae radix), Mu Xiang ( Aucklandiae radix)**, Qing Pi ( Citri reticulatae viride pericarpium) and Xiao Hui Xiang ( Foeniculi fructus)
When the internal cold accumulates in the body, whatever the cause is, cold may contract the meridians, collaterals and muscles. The Qi gets obstructed and pain appears in the affected area. Herbs that promote the Qi movement and are warm in nature are used in these conditions to assist the herbs that warm the interior, expel cold, open up the meridians and therefore alleviate pain. Since they enter different meridians and regions, they may be selected to treat Qi obstruction in the related area.
Wu Yao enters the Kidney and Bladder meridians, and is used mainly to release cramping pain in the lower and lower-lateral sides of the abdomen.
Mu Xiang enters the Liver, Spleen, Stomach and Large Intestine meridians, and can effectively release pain in the hypochondriac region and in the whole abdomen, especially when distension and irregular bowel movement exist.
Qing Pi is used mainly to treat pain due to Liver-Qi stagnation as it enters the Liver meridian.
Xiao Hui Xiang can gently and effectively warm the Middle- and Lower-Jiao and treat abdominal pain and distension.
Cang Zhu ( Atractylodis rhizoma), Bai Zhu ( Atractylodis macrocephalae rhizoma), Sheng Jiang ( Zingiberis rhizoma recens) and Cao Dou Kou ( Alpiniae katsumadai semen)
Damp-cold accumulation often coexists in Yang deficiency syndrome. Because cold obstructs the meridians, this leads to obstruction of Qi movement and water circulation, and cold-dampness is thus formed. Moreover, when the Yang is too weak to steam the fluid into Qi and Yin, the water metabolism becomes very slow and the water may accumulate in certain places in the body. In this condition, herbs that are warm in nature and have the function of transforming dampness should be used as assistants in formulas.
Cang Zhu is very pungent, bitter and warm. It enters the Spleen and Stomach meridians. It is drying in nature, and can expel wind, damp and cold, and treat painful and heavy joints and muscles. It can dry the damp-cold in the Middle-Jiao and treat reduced appetite and fullness in the abdomen. A white, sticky and thick tongue coating should be present when this herb is selected. Since it is drying in nature, it is only used in the excess condition of dampness accumulation and should be used for a short period of time only.
Bai Zhu is less bitter and warm than Cang Zhu and has no pungent taste. The strong point of this herb is tonifying the Spleen-Qi and, at the same time, drying the dampness in the Middle-Jiao. It is particularly suitable for use in conditions where the Spleen is too weak to transform and transport the fluid. This herb can be used for a long period of time.
Sheng Jiang is pungent and warm, and primarily enters the Stomach and Lung meridians. It regulates the Qi, disperses cold and dampness, and soothes the Stomach-Qi. It treats cold sensation in the stomach, nausea and vomiting, such as after indulgence in cold food and drink, or in the common cold or influenza.
Cao Dou Kou is pungent and warm, and enters the Spleen and Large Intestine meridians. It can effectively warm the Middle-Jiao, dry dampness and promote the Qi movement. It is often selected to treat abdominal distension and pain with cold sensation and poor digestion.
Wu Wei Zi ( Schisandrae fructus) and Bai Shao Yao ( Paeoniae radix lactiflora)
Wu Wei Zi is sour and warm, and enters the Heart and Kidney meridians. The sour taste gives Wu Wei Zi a binding ability. It can stabilize the Yang and Qi in formulas that rescue the Yang when Yang almost collapses. In addition, the sour taste can moderate the actions of the harsh, pungent and hot herbs used for the same condition because the harsh herbs may stimulate the Yang too strongly and too quickly, which may scatter the Yang. These herbs may also injure the Yin, eventually leading to weaker control of the Yang and worsening the condition of Yang collapse.
Bai Shao Yao is sour and cold, and primarily enters the Liver meridian. The sour and cold properties can generate the Yin. It can be used in formulas that warm the Yang so as to protect the Yin from hot and pungent herbs. Moreover, its sour taste can stabilize the Yang and the Qi, as well as moderating the speed of the pungent and hot herbs.
Zhu Dan Zhi ( Pulvis bovis) and Huang Bai ( Phellodendri cortex)
These substances are used as strategic assistants in formulas that rescue the Yang from collapse. When Yang collapses, the internal cold is in excess inside the body, and is at variance with the efforts of pungent and hot herbs which try to get into the body. The conflict of these two completely different natures is manifested in symptoms such as vomiting out the herbal drink, irritability, irregular pulse and other uneasy sensations. One method to solve this problem is to add a small amount of cold herb, such as Zhu Dan Zhi or Huang Bai, to a large amount of hot herbs to moderate the conflict between the pathological cold and the hot herbs. Another method of moderating the conflict is to ask patients to take the herbal drink when it is cooled down. This strategy is called assisting in an opposite way.
Envoy: Harmonize the herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata), Sheng Jiang ( Zingiberis rhizoma recens) and Da Zao ( Jujubae fructus)
Zhi Gan Cao is sweet in nature and enters the Spleen meridian. It can harmonize the herbs that warm the interior in a formula. It can also reduce the side effect of harsh herbs and protect the Stomach. Sheng Jiang and Da Zao are used together to tonify the Middle-Jiao and promote digestion, as well as protect the Stomach from the pungent and hot herbs.
Examples of classical formulas
Li Zhong Wan (Regulate the Middle Pill) 
Source: Shang Han Lun 
Composition
Ren Shen ( Ginseng radix) 6 g
Gan Jiang ( Zingiberis rhizoma) 5 g
Bai Zhu ( Atractylodis macrocephalae rhizoma) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Analysis of the formula
This formula can warm the Middle-Jiao and strengthen the Spleen-Yang. It treats internal cold due to Spleen-Yang deficiency.
• The chief herbs are Gan Jiang and Ren Shen. Gan Jiang can effectively and quickly warm the Middle-Jiao and Ren Shen can strongly tonify the Spleen-Qi. They strengthen each other’s function, spread the Yang and scatter the coldness in the body.
• Bai Zhu, as deputy, tonifies the Spleen-Qi and enhances the ability of the Ren Shen. It can also dry the dampness that has developed from the Yang deficiency in the Middle-Jiao and it enhances the function of Gan Jiang to spread the Yang.
• Zhi Gan Cao serves as assistant as well as envoy. It is able to tonify the Spleen, and harmonize and moderate the actions of the herbs in this formula.
Commentary on strategies
• In this formula, each group of herbs has a specific function and represents one aspect of the treatment for the purpose of constructing the Yang of the Middle-Jiao.
• It is in the form of a pill that is made with honey, which assists Yang generation in the Middle-Jiao in a steady and sufficient way. It is particularly useful in chronic conditions of Spleen-Yang deficiency.
Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) 
Source: Shang Han Lun 
Composition
Yi Tang ( Maltose) 30 g
Gui Zhi ( Cinnamomi cassiae ramulus) 9 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Sheng Jiang ( Zingiberis rhizoma recens) 10 g
Da Zao ( Jujubae fructus) 4 pieces
Analysis of the formula
This formula primarily treats Spleen-Qi and Yang deficiency. In fact, it treats a chronic syndrome of deficiency of the Middle-Jiao, where not only Qi and Yang, but also Yin and blood are deficient, due to long-term Yang and Qi deficiency.
• The Yang and Qi deficiency is manifested as intermittent, spasmodic abdominal pain that responds favorably to local application of warmth and pressure, reduced appetite, cold and sore extremities.
• The Qi and blood deficiency is manifested as a lusterless complexion, palpitations, a pale tongue and a thready pulse.
• The Yin deficiency shows in low-grade fever, dry mouth, dry throat and irritability. Since Qi, blood, Yin and Yang are deficient in the Middle-Jiao in different degrees, this leads to a treatment dilemma: if tonifying the Yang by using pungent and hot herbs, the Yin and blood can be injured; if nourishing the Yin and blood by using cold and sour herbs, the Yang and Qi will be injured.
The formula Xiao Jian Zhong Tang demonstrates the use of important strategies so that all the aspects may be tonified in a balanced and sufficient way.
• A large amount of Yi Tang is applied as the chief ingredient. Since it is sweet and neutral and enters the Spleen meridian, it can tonify the Spleen directly without harming the Yin or the Yang. Since its nourishing nature makes it perfect for smoothing the muscles, it can relieve cramping pain.
• When Yi Tang and pungent-sweet-hot Gui Zhi, one of the deputy herbs, are used together, they can tonify the Spleen-Yang and stimulate its function. As the pungent and hot nature of Gui Zhi is modified by the large amount of Yi Tang, this herb will not injure the Yin and blood.
• When Yi Tang and sour-bitter-cold Bai Shao Yao, another deputy herb, are used together, they can generate the Yin of the body and in this way treat the blood and Yin deficiency. As the cold nature of Bai Shao Yao is minimized by the large amount of Yi Tang, Bai Shao Yao will not injure the Yang and Qi.
• The pungent and hot Sheng Jiang stimulates the Yang and is used as assistant to enhance the ability of Gui Zhi to warm the Middle-Jiao. It also soothes the Stomach-Qi, disperses cold and water accumulation and improves digestion.
• The sweet and warm Da Zao can tonify the blood and Spleen-Qi and serves as assistant to enhance the ability of Bai Shao Yao.
• Zhi Gan Cao works as assistant as well as envoy. It can tonify the Spleen and ease the muscles, thus assisting the chief herb. As envoy, it moderates the action of the other herbs.
Commentary on strategies
There are several distinct characteristics to this formula.
• First of all, sweet herbs are used to tonify the Spleen directly.
• Second, the combination of sweet and warm herbs, and sweet and cold herbs is used to generate the Yang and Yin respectively.
• Third, the combinations and ratios of dosages are arranged in a thoughtful way to avoid the side effect of injury to the other aspects in the process of tonifying one party. In this way, the Yin, Yang, Qi and blood are generated gradually, steadily and sufficiently.
When the Yin and blood can nourish the internal organs, the Yang and Qi can accelerate their functions, and all symptoms disappear gradually. This formula is a very good example for treating chronic conditions.
Hui Yang Jiu Ji Tang (Restore and Revive the Yang Decoction) 
Source: Shang Han Liu Shu 
Composition
Shu Fu Zi (processed Aconiti radix lateralis preparata)* 9 g
Gan Jiang ( Zingiberis rhizoma) 5 g
Rou Gui ( Cinnamomi cassiae cortex) 3 g
Ren Shen ( Ginseng radix) 6 g
Bai Zhu ( Atractylodis macrocephalae rhizoma) 9 g
Fu Ling ( Poria) 9 g
Chen Pi ( Citri reticulatae pericarpium) 6 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 5 g
Wu Wei Zi ( Schisandrae fructus) 3 g
Ban Xia ( Pinelliae rhizoma) 9 g
Sheng Jiang ( Zingiberis rhizoma recens) 3 pieces
She Xiang ( Moschus)** 0.1 g
Dosages are added, as they were not recorded in the source book.
Analysis of the formula
This formula can rescue the Yang from collapse and tonify the Qi. It is used to treat severe Yang deficiency of the Kidney, Spleen and Heart, and accumulations of cold in the body. The symptoms are extremely cold extremities, an exhausted state with a constant desire to sleep, vomiting, diarrhea with undigested food particles, abdominal pain and cold, severe chills, purple color of nails and lips, a pale tongue with a white coating, and a weak and deep pulse.
In this formula:
• Fu Zi is used as chief herb to stimulate the Yang and expel cold. It is especially used in the critical condition of Yang collapse. The processed Fu Zi is gentler than the raw one, and is more suitable for a critical condition where both Yang and Yin are weak and the Yin can barely hold the Yang. Raw Fu Zi is very pungent and hot; it stimulates Yang too quickly and too strongly, which may break the fragile binding of the Yin and Yang of the body and worsen the condition of Yang collapse. Processed Fu Zhi is used to avoid this effect.
• Rou Gui and Gan Jiang are used as deputies to ensure the strength of rescuing the Yang. Rou Gui enters the Kidney, warms the Kidney-Yang and enhances the function of Fu Zi. In addition, it can strengthen the vital-gate fire and bring the floating-Yang back to its source, which is particularly necessary at this moment. It is sweet in taste, can tonify the body and maintain a steady action of warming the Lower-Jiao, the Kidney. Gan Jiang enters the Spleen meridian. It directly warms the Spleen-Yang and eliminates the cold and dampness, thereby enhancing the function of the chief.
• Ren Shen and Zhi Gan Cao are used as assistants to tonify the Qi in general in order to enhance the ability of the chief herb to stabilize the Yang in a critical condition.
• There are several helping assistants in the formula: Bai Zhu and Fu Ling tonify the Spleen-Qi and eliminate the dampness; Ban Xia and Chen Pi regulate the Qi in the Middle-Jiao and remove dampness and phlegm that are generated by the weakened digestion and Yang deficiency; She Xiang can intensively and quickly open up all meridians and enhance the action of the spreading of Yang-Qi owing to its very strong aromatic nature.
• Wu Wei Zi, another assistant, is warm and sour, and enters the Lung, Heart and Kidney meridians. Its sour property can stabilize the Yang in the condition of Yang collapse. Moreover, with sweet herbs, it can generate Yin and therefore control the Yang. When it is used with Ren Shen, the Kidney-Qi is strengthened and stabilized. This can help stabilize the Yang tremendously. When Wu Wei Zi is used with She Xiang, the Qi moves in the body in a smoother way. This is because She Xiang can disperse the Qi and Wu Wei Zi can stabilize the Qi. It serves as corrective assistant to reduce the harsh nature of the hot and pungent herbs in the formula.
• Zhi Gan Cao is used as envoy. It can harmonize the function of the herbs in the formula.
When the herbs are used together, the Yang, the Yin and the Qi are strengthened and their relationships become more stable. In this way Yang collapse can be prevented and treated.
Commentary on strategies
This formula shows the methods and cautions of rescuing the Yang in a critical condition by using processed Fu Zi instead of the raw version.
• It focuses not only on treating the Kidney but also on tonifying the Spleen in light of the relationship between Kidney and Spleen.
• It focuses on rescuing and stabilizing the Yang; however, herbs that strengthen the Qi are used which take account of the relationship of Yang and Qi.
All the arrangements in this formula bring inspiration to the study of strategies for treating critical conditions by considering the relationships of all the involved aspects.
Dang Gui Si Ni Tang (Tongue Decoction for Frigid Extremities) 
Source: Shang Han Lun 
Composition
Dang Gui ( Angelicae sinensis radix) 12 g
Gui Zhi ( Cinnamomi cassiae ramulus) 9 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Xi Xin ( Asari herba)* 1.5 g
Gan Cao ( Glycyrrhizae radix) 5 g
Tong Cao ( Tetrapanacis medulla) 3 g
Da Zao ( Jujubae fructus) 8 pieces
Analysis of the formula
This formula is able to warm the meridians and expel cold, tonify the blood and promote blood circulation. It is used to treat cold and painful joints and muscles due to Yang deficiency and blood deficiency with invasion of external cold. A pale tongue with a white coating and a very thready and deep pulse are the important signs of this syndrome.
In this formula:
• Dang Gui, as chief, is used in a large dosage. It is warm, sweet, bitter and pungent, and can directly tonify the blood and promote the blood circulation.
• The pungent-warm Gui Zhi, which enters the Heart meridian, is used as deputy to enhance the ability of Dang Gui. It can effectively stimulate the Yang and warm the blood. Gui Zhi also enters the Lung meridian, so can expel the cold and spread the Yang and Qi in the entire body.
• Another deputy is Xi Xin. It is pungent and hot, and enters the Kidney meridian. It can stimulate the Kidney-Yang and Qi, expel the cold, warm the meridian and effectively reduce the cold and pain of the joints.
• Bai Shao Yao is also used as deputy alongside the pungent and warm herbs. It is sour and cold. Together with sweet herbs, such as Dang Gui, Gui Zhi and Da Zao, it can nourish the Yin and tonify the blood, paying attention to the material aspect of the blood, and therefore can indirectly strengthen the relationship between the Yin and Yang.
• Gan Cao and Da Zao are assistants in the formula. They are sweet, can tonify the Spleen and accelerate the transforming function of the Spleen. In addition, they directly aid Dang Gui and Bai Shao to tonify blood, and aid Gui Zhi and Xi Xin to strengthen the Yang.
• Tong Cao is used as envoy in the formula. It is cold in nature and enters the Heart meridian. It guides the other herbs entering the Heart meridian and enables them to carry out their functions. It is also used as corrective assistant to prevent the hot herbs injuring the blood. Its action has a descending quality, which can control the side effect of Xi Xin that may ascend and stimulate the weakened Kidney-Yang too quickly.
Commentary on strategies
• The combination of sweet and warm herbs creates the strong and steady action of this formula in warming the Yang and blood without harsh effect.
• The combination of warm, sweet and sour herbs creates a balanced action of this formula in warming the Yang without the side effect of injuring the blood and Yin.
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| Figure 4.1 •. |
| Etiology and pathology of internal cold syndrome. |
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| Figure 4.2 •. |
| Pathology of syndrome of Yang collapse. |
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| Figure 4.3 •. |
| Pathology of floating-Yang syndrome. |
