Chapter Nineteen. Yong (carbuncle) and Yang (ulceration) syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for composing the formulas that can clear heat, transform dampness, discharge pus, push out toxin and promote healing. They treat boils, carbuncles, ulcerations and localized open or closed wounds.
Syndrome of Yong Yang
In Chinese, Yong means carbuncle and Yang means ulceration. Yong Yang is a collective term in traditional Chinese medicine for boils, carbuncles, ulceration and localized open or closed wounds. Since these disorders are located on the skin, are observable and palpable, they are recognized as a special syndrome in differentiation. According to differences in causes, manifestations and signs, Yong Yang can be subdivided into Yang syndrome and Yin syndrome. The treatments are different.
1. Yang syndrome
The Yang type of Yong Yang syndrome is characterized by localized redness, swelling, hot sensations and pain. High fever and general pain may also exist. This syndrome appears in acute inflammations, such as carbuncles, furuncles, abscesses and infected open wounds. The book The Yellow Emperor’s Classic of Internal Medicine indicated: ‘Most of the sores which are painful, itchy and swollen are due to fire.’ In clinical practice, this syndrome is mainly related to fire disturbance of the Heart, Liver and Stomach.
The Heart is a fire organ and its fire can easily flare up in a pathological condition. The Heart-fire can also be rapidly increased by the influence of Liver-fire because the Liver is its mother organ. The blazing Heart-fire can easily generate fire-toxin and lead to a fire-toxin syndrome.
The Stomach is another source of excess fire in the body. It is a Yang Ming organ and is responsible for receiving, ripening and transporting food. All these activities increase and produce heat, and lead to fire-toxin syndrome.
A Yang-type Yong Yang syndrome often appears when patients are subject to strong emotions or are under stress, which can quickly generate internal heat-toxin, injure the flesh and blood, and lead to boils and carbuncles. A Yang-type Yong Yang syndrome is also caused by inappropriate dietary habits such as overindulgence in spicy, greasy, sweet foods and alcohol, which easily generate heat and dampness in the Middle-Jiao and influence the subcutaneous region. This situation frequently occurs in a person with a Yang constitution or a patient who suffers from internal heat due to chronic disease or taking certain medication.
Manifestations
Main symptoms
Boils, carbuncles, ulceration and localized open wounds with signs of redness, swelling, heat and pain.
Secondary symptoms
Acute condition
At the initial stage: Fever, chills, generalized pain of the body. The boil or carbuncle is hard and painful.
At the metaphase stage: Pus is formed, thus the boil or carbuncle becomes soft and the pain is less severe.
At the recovery stage: Perforation occurs, pus is discharged and the healing process starts.
Chronic condition
Pus is formed but the boil or carbuncle does not readily perforate, and the localized lesion is accompanied by mild pain, swelling and a warm sensation.
Tongue
Red tongue with yellow coating.
Pulse
Wiry, rapid and forceful.
Associated disorders in western medicine
Carbuncles, furuncles, abscesses and infected open wounds.
Analysis of the syndrome
• When heat accumulates in the skin, subcutaneous region and muscles, the patient may feel hot in the affected region and observe a red color of the skin lesions.
• Heat obstructs the Qi and blood, and causes swelling and pain.
• If heat disturbs the normal movement of Defensive-Qi in the superficial region of the body, chills and fever may appear at the initial stage.
• Heat-toxin with stagnant dampness, Qi and blood may form a hard and painful lesion.
• When excess heat blazes in the blood and flesh, pus is eventually formed.
• If the Qi and blood are strong enough in the body, the body’s resistance can push out the toxin. The lesion thus perforates, pus is discharged, and the pain and the hot sensation are reduced.
• When Qi movement and blood circulation are improved in the local region, the healing process starts.
• If the body’s resistance is not strong, the Qi and blood are too weak to push out the toxin. Pus forms but the boil or carbuncle does not perforate and discharge pus. The disorder then leads to a chronic process.
(See Figure 19.1 on page 395.)
Treatment principle
• At the initial stage: Clear heat-toxin and reduce swelling so as to prevent further development of the syndrome.
• If the pus is forming but the boil or carbuncle is not ready to perforate: Activate Qi and blood, accelerate formation of pus and perforation of the boil or carbuncle.
• If the pus is formed and the boil or carbuncle becomes soft and less painful: Discharge the pus by promoting perforation or making an incision.
• After pus has been discharged: Tonify the Qi, nourish Yin and stimulate the blood in order to promote the healing process.
Herb selection principles and formula composition strategies
• At the initial stage, the first priority is to select pungent-cold herbs or bitter-cold herbs that can effectively reduce heat-toxin, along with herbs that expel wind. They can prevent the development of the syndrome.
• At the metaphase stage, the first priority is to select pungent-cold herbs that accelerate perforation of the boil or carbuncle and discharge pus, along with herbs that cool the blood. Herbs that can stimulate Qi and blood so as to accelerate the formation of pus are often used when pus is forming.
• At the recovery stage, the first priority is to select herbs that tonify the Qi and Yin. Herbs that remove dampness and promote blood circulation are also used.
• In a chronic condition, herbs that tonify the Qi and herbs that promote blood circulation are used, along with herbs that remove heat-toxin and dampness.
Structure of the formula and selection of herbs
Chief: Clear wind-heat, remove heat-toxin or damp-heat in order to stop the pathogenic development at the initial stage
Jin Yin Hua ( Lonicerae flos) and Lian Qiao ( Forsythiae fructus)
Jin Yin Hua is sweet and cold, and enters the Heart, Liver and Stomach meridians. It is a strong herb to clear heat in these organs and meridians. Its sweet and cold properties may generate body fluids so it can prevent Yin consumption from internal heat. As Jin Yin Hua is collected in the early summer when the flowers are still in bud, this herb has a light fragrant smell that has dispersing and ascending abilities. It may slightly disperse and ascend the fire, especially the constrained fire, and can therefore effectively clear heat and remove heat-toxin. Because of these characteristics, it is often selected as chief at the initial stage of Yang-type Yong Yang syndrome.
Lian Qiao is less cold than Jin Yin Hua but has a bitter taste. It enters the Heart and Small Intestine meridians. Bitterness may descend fire from the Heart and cold may clear heat. This herb possesses strong dispersing and ascending abilities and is especially effective in dispersing heat in the Heart and relieving restlessness and a warm sensation in the chest. It is also able to dissipate clumps and nodules caused by constrained heat, accumulation of food and phlegm, and stagnation of blood. Its dispersing and dissipating actions are stronger than those of Jin Yin Hua. It is especially used for treating Yang-type Yong Yang syndrome caused by blazing Heart-fire.
As Jin Yin Hua and Lian Qiao have similar properties and actions, they are often used together to enhance the strength of reducing heat-toxin.
Pu Gong Ying ( Taraxaci herba), Di Ding ( Violae herba) and Ye Ju Hua ( Chrysanthemi indici flos)
These herbs can strongly reduce heat-toxin and are often applied in the formula to treat Yang-type Yong Yang syndrome.
Pu Gong Ying is bitter, sweet and cold, and enters the Liver and Stomach meridians. It can effectively reduce swelling and clear heat-toxin. It can be used at the initial stage of boils and carbuncles when they are warm and swelling. The fresh herb of Pu Gong Ying can be smashed and applied on the swelling and painful places. When there is an ulcer characterized by a red color, a hot sensation and burning pain, Pu Gong Ying can also be used. In this case, it is not only used orally, but also topically as a local compress after the herb is cooked.
Di Ding is bitter, pungent and cold, and enters the Heart and Liver meridians. It should be selected in the formula if a boil is hard, deep-based and very painful. It is suitable for use when the cause of the disorder is blazing Heart-fire rather than heat in the Stomach.
Ye Ju Hua is bitter and neutral, and enters the Lung, Liver and Kidney meridians. It can effectively clear heat-toxin and also reduce swelling. Like Pu Gong Ying, it can be used both orally and topically.
Huang Qin ( Scutellariae radix), Huang Lian ( Coptidis rhizoma), Huang Bai ( Phellodendri cortex), Zhi Zi ( Gardeniae fructus) and Long Dan Cao ( Gentianae radix)
These herbs are very cold and bitter, and can intensively clear heat and dry dampness. They treat severe damp-heat syndrome, which can be observed in infections of skin and subcutaneous regions, ulcers, eczema and some open wounds where the lesions are red, painful and weeping. When a person has fat skin or overindulges in greasy, sweet and pungent food, skin infections with thick pus can develop easily, which is considered as damp-heat accumulation in syndrome differentiation. Huang Qin, Huang Lian and Huang Bai are often selected in the formula to remove the damp-heat. If Yang-type Yong Yang syndrome is linked directly with strong emotions and stress, Huang Lian and Long Dan Cao are often used as they enter the Heart and Liver meridians and can reduce the blazing fire.
These herbs can be used separately according to the syndrome features and location of the lesions.
Huang Qin enters the Lung and Large Intestine meridians. It particularly clears heat in the Lung and the Upper-Jiao and damp-heat in the intestine. As skin is related to the Lung, Huang Qin can be used for the initial and metaphase stages of Yang-type Yong Yang syndrome, which is characterized by itchy and red superficial skin eruptions, and red and weeping ulcers. When damp-heat also accumulates in the Large Intestine due to inappropriate dietary habit with symptoms such as sticky and stinking feces, this herb is more suitable for selection.
Huang Lian enters the Heart and Stomach meridians. It can strongly reduce fire in the Heart and Stomach, and treat boils or carbuncles developed under stress and strong emotions, or due to consumption of very spicy food.
Huang Bai enters the Kidney and Bladder meridians. It can clear heat and dry dampness in the Lower-Jiao. It is an appropriate herb to treat boils and carbuncles in the groins, buttocks and external genital area. It is also used for treating pruritus vulvae, scrotitis and penitis due to damp-heat in the Lower-Jiao and disturbance of empty-fire of the Kidney.
Huang Qin, Huang Lian and Huang Bai can also be applied topically in lotions or pastes to clear heat and dry dampness. They can also be used together in a cream, called San Huang Gao (the three yellow cream), to treat boils and carbuncles.
Zhi Zi enters the San Jiao meridian. It can be combined with any other herbs in this group to enhance their function of clearing heat. At the same time, it leaches out the damp-heat by promoting urination. The latter is the strong point of this herb as it can clear damp-heat of the Heart, Liver and Bladder and lead it to exit the body by urination.
Long Dan Cao enters the Liver meridian and can strongly clear Liver-heat. If Yang-type Yong Yang syndrome appears on the lateral sides of the face, neck and hypochondriac region, such as in cases of herpes zoster, Long Dan Cao can be selected. Long Dan Cao can also be selected in the formula to treat damp-heat in the Liver meridian in the Lower-Jiao, such as in cases of vaginitis, scrotitis and penitis.
Deputy: Promote blood circulation and reduce heat in the blood
Chuan Xiong ( Chuanxiong rhizoma), Dan Shen ( Salviae miltiorrhizae radix), Mu Dan Pi ( Moutan cortex) and Chi Shao Yao ( Paeoniae radix rubra)
Chuan Xiong is pungent and warm, and enters the Liver, Gall Bladder and Pericardium meridians. Pungency can disperse congealed blood, and warmth can activate blood circulation and dissipate blood stagnation. Chuan Xiong is a very effective herb to invigorate blood and to promote blood circulation. It is characterized by high moving speed and strength. For treating Yang-type Yong Yang syndrome, since it can remove congealed blood and reduce pain, it can be selected at all stages of the disorder. It should be mentioned that this herb is warm and very pungent, and a large dosage or long-term use may consume the Yin and Qi. Herbs that nourish the Yin and tonify the Qi should therefore be selected along with Chuan Xiong when treating a chronic condition.
Dan Shen is bitter and slightly cold, and enters the blood level of the Heart and Liver meridians. It is able to promote blood circulation, cool the blood, calm the mind and eliminate irritability. It is a good choice for treating Yang-type Yong Yang syndrome when the color of the skin turns to deep red or purple, which indicates stagnation of blood. Dan Shen can also be applied topically to reduce pain and swelling. The syndrome is often caused by stress and emotional disturbance, which lead to Liver-Qi stagnation, Liver-fire or Heart-fire generation, when the heat further enters the blood and consumes the blood.
Mu Dan Pi and Chi Shao Yao are both cold in nature. They are very often used for cooling the blood and treating heat in the blood. Moreover, they are both able to promote blood circulation and are often chosen because they have fewer side effects than other cold herbs of generating congealed blood in the process of cooling the blood.
Chi Shao Yao is bitter and cold, and enters the Liver meridian, the blood level. It is especially effective in clearing excess heat in the blood. As it is strong in promoting blood circulation and removing congealed blood, it can effectively alleviate pain and reduce swelling. Moreover, it is one of the commonly selected herbs to apply topically to relieve pain and reduce swelling in strain and acute closed injury.
Mu Dan Pi is pungent and cold, and enters the Liver meridian. It is able to clear empty-heat in the blood and is often selected in the formula to treat a sub-acute condition of Yang-type Yong Yang syndrome when the excess heat has consumed the Yin, especially the Liver-Yin.
Zi Cao ( Arnebiae/Lithospermi radix) and Qian Cao Gen ( Rubiae radix)
Zi Cao is salty, sweet and cold, and enters the Heart and Liver meridians; Qian Cao Gen is bitter and cold, and enters the Liver and Pericardium meridians. These two herbs enter the blood and cool the blood. At the same time, they can reduce congealed blood. Qian Cao Gen can also stop bleeding. They are particularly selected in the condition when the skin lesion is deep red or purple in color, which suggests that heat has entered the blood and blood stagnation exists, such as in the sub-acute or chronic condition of boils and carbuncles, ulcers, closed injury of muscles and joints, or bleeding under the skin.
Assistant: Transform dampness, discharge pus and promote healing
Gua Lou ( Trichosanthis fructus), Pu Gong Ying ( Taraxaci herba), Xia Ku Cao ( Prunellae spica), Zhe Bei Mu ( Fritillariae thunbergii bulbus) and Wang Bu Liu Xing ( Vaccariae semen)
All of these herbs are able to promote pus formation, and therefore the boil or carbuncle will soon be ready to perforate or be incised. As soon as the pus can be discharged, the healing process can start.
Gua Lou and Pu Gong Ying can accelerate and increase pus formation, eliminate dampness and phlegm, and clean up the purulent lesion. They are often used in the metaphase of Yang-type Yong Yang syndrome. Xia Ku Cao and Zhe Bei Mu have a pungent nature, can break up phlegm accumulation and soften hardness, and are particularly applied at the early stage of metaphase of Yong Yang syndrome when the boil or carbuncle is hard and painful, with no chance of reduction as there might have been at the initial stage. The only solution is to accelerate the process of pus formation and push out the toxin.
Wang Bu Liu Xing is bitter and neutral, and enters the Liver and Stomach meridians. It has a strong moving ability and enters the blood level. It can promote Qi movement, eliminate stagnant blood and open up the collaterals. It is often selected when obstruction of dampness, phlegm, Qi and blood exists at the metaphase stage of the boil or carbuncle. It can accelerate perforation and discharge pus.
Wang Bu Liu Xing ( Vaccariae semen), Zao Jiao Ci ( Gleditsiae spina) and Chuan Shan Jia ( Manitis squama)**
These substances are all able to promote the perforating process of boils or carbuncles. When pus has been formed, pain becomes less severe. They can activate the Qi movement, open up the obstruction of dampness and phlegm, break up blood stagnation and thus activate perforation so as to clean up the wound.
Dong Gua Zi ( Benincasae semen), Lu Gen ( Phragmitis rhizoma) and Yi Yi Ren ( Coicis semen)
These three herbs are sweet and cold, and can clear heat, transform dampness, discharge pus and clean up the wound. Moreover, these herbs can eliminate dampness without the side effect of injuring the body fluids. They are frequently used when perforation has already taken place and the open wound is purulent.
Dong Gua Zi enters the Lung, Stomach, Large Intestine and Small Intestine meridians. It has a lubricating nature and can clear heat from the Lung and eliminate accumulation from the Large Intestine. It is able to transform phlegm and discharge pus, and is often used for treating abscesses of the Lung and intestines, and purulent open wounds.
Lu Gen enters the Lung, Stomach and Kidney meridians. It is effective in clearing heat of the Lung and transforming phlegm and damp-heat there. It is often used for treating abscesses in the Lung and purulent open wounds.
Yi Yi Ren is sweet, bland and slightly cold, and enters the Spleen, Stomach and Lung meridians. Similar to Dong Gua Zi and Lu Gen, it is able to transform damp-heat and discharge pus, and is often used for treating abscesses in the Lung and the intestines. It is also able to discharge pus from open wounds.
Bai Zhi ( Angelicae dahuricae radix) and Fang Feng ( Saposhnikoviae radix)
Bai Zhi is an aromatic herb and Fang Feng is pungent in nature. These two herbs enter the Spleen meridian. Since they can eliminate dampness and transform pus, they are often used to clean up the purulent open wound and promote the healing process.
Ku Shen ( Sophorae flavescentis radix), Bai Xian Pi ( Dictamni cortex), Di Fu Zi ( Kochiae fructus) and Huang Bai ( Phellodendri cortex)
These herbs are able to clear heat and dry dampness. They are particularly used when the skin lesions are very red, itchy and weeping, indicating accumulation of damp-heat. They are selected not only for treating boils and carbuncles, but also other skin disorders such as eczema with infections caused by viruses, bacteria, fungi and parasites. They can also be applied topically to relieve itch and dry oozing. They are often used as assistants in the formula to enhance the ability of herbs that strongly reduce damp-heat, such as Huang Qin ( Scutellariae radix), Huang Lian ( Coptidis rhizoma) and Huang Bai ( Phellodendri cortex).
Huang Qi ( Astragali radix), Dang Gui ( Angelicae sinensis radix) and Sheng Ma ( Cimicifugae rhizoma)
These herbs are used when the pus is formed but is thin and scanty, which indicates that the Qi and blood are too weak to push out the toxin and promote perforation so as to discharge the pus. If this situation lasts for a long period of time, the healing process is unable to start, and the disorder leads to a chronic process.
Huang Qi is sweet and warm, and enters the Spleen and Lung meridians. As it can strengthen the Spleen-Qi and Lung-Qi, it can also strengthen the muscles and the subcutaneous region. It can promote pus formation and pushing out toxin in the condition where the body’s resistance is too weak to fight against pathogenic heat-toxin, and is unable to accelerate perforation to discharge pus.
The pungent and warm Dang Gui can enhance this function of Huang Qi because it can tonify the blood, promote blood circulation and improve blood supply in the local region. At the same time, Sheng Ma may also be used as it enters the Spleen meridian and has an ascending nature. It can increase the strength of Huang Qi in ascending the Spleen-Qi so as to push out the toxin.
Examples of classical formulas
Xian Fang Huo Ming Yin (Sublime Formula for Sustaining Life) 
Source: Jiao Zhu Fu Ren Liang Fang 
Composition
Jin Yin Hua ( Lonicerae flos) 9 g
Fang Feng ( Saposhnikoviae radix) 3 g
Bai Zhi ( Angelicae dahuricae radix) 3 g
Dang Gui ( Angelicae sinensis radix) 6–12 g
Chi Shao Yao ( Paeoniae radix rubra) 3 g
Ru Xiang ( Olibanum) 3 g
Mo Yao ( Myrrhae) 3 g
Tian Hua Fen ( Trichosanthis radix) 3 g
Chuan Shan Jia ( Manitis squama)** 3 g
Zao Jiao Ci ( Gleditsiae spina) 3 g
Chen Pi ( Citri reticulatae pericarpium) 9 g
Sheng Gan Cao ( Glycyrrhizae radix) 3 g
Rice wine
Analysis of the formula
This formula can clear heat and eliminate heat-toxin, reduce swelling and promote discharge of pus. It can also invigorate blood and alleviate pain. This formula is used in the early metaphase of Yang-type boils and carbuncles due to fire-toxin and phlegm-fire in the body. This manifests as red, swollen, hot and painful skin lesions that are usually accompanied by fever, mild chills and headache. The patient has a thin, yellow or white tongue coating and a rapid and forceful pulse.
In this formula:
• Jin Yin Hua is used as chief to clear heat-toxin directly. Since it is a flower and has an ascending tendency in action, it can also disperse constrained heat and expel pathogenic heat. The pungent Fang Feng and Bai Zhi serve as deputies to enhance this function of Jin Yin Hua.
• Dang Gui, Chi Shao Yao, Ru Xiang and Mo Yao can regulate blood and dissipate congealed blood, as well as reduce the swelling and alleviate pain.
• Zhe Bei Mu, Tian Hua Fen can clear heat and dissipate hard swelling so as to reduce pain.
• Chuan Shan Jia and Zao Jiao Ci can open the meridians and activate the Qi and blood in the collaterals, promote discharge of pus and break up hardness. They are used as assistants.
• Chen Pi is used as assistant to regulate the Qi. Gan Cao is used as both assistant and envoy to reduce heat-toxin and harmonize the herbs in the formula.
Commentary on strategies
This formula demonstrates several treatment principles for the Yang type of sores and carbuncles.
• Directly clear hear-toxin and expel the pathogenic factor so as to treat the cause of the disorder.
• Promote blood circulation so as to open the blockage and reduce swelling and pain. This can assist the body’s resistance in the local region.
• Chuan Shan Jia and Zao Jiao Ci are the substances that are particularly used in Yong Yang syndrome. When boils and carbuncles are at the early metaphase stage, these substances can reduce swelling and soften hardness by activating the Qi and blood in the local region and breaking up the obstruction. At the late metaphase stage, these substances can accelerate perforation of boils or carbuncles and discharge pus. In this way, they promote the healing process.
• Since Chuan Shan Jia and Zao Jiao Ci are used in the formula, it is neither applicable for the initial stage of boils and carbuncles nor when perforation has taken place.
Wu Wei Xiao Du Yin (Five-Ingredient Decoction to Eliminate Toxin) 
Source: Yi Zong Jin Jian 
Composition
Jin Yin Hua ( Lonicerae flos) 20 g
Di Ding ( Violae herba) 15 g
Tian Kui Zi ( Semiaquilegiae radix) 15 g
Pu Gong Ying ( Taraxaci herba) 15 g
Ye Ju Hua ( Chrysanthemi indici flos) 15 g
Analysis of the formula
This formula can clear heat, relieve fire-toxin, cool the blood and reduce swelling. It is used for treating Yang-type boils and carbuncles in metaphase. The skin lesions are very red, swollen, hot and painful, and are usually accompanied by fever and chills. This formula especially treats a hard lesion which is small in size but deep-seated and very painful. The patient often has a red tongue with a yellow coating and a rapid pulse.
This syndrome is cause by exogenous pathogenic heat which generates fire-toxin. Heat causes stagnation and produces more accumulation, which generates more heat. As this cycle continues, the accumulated fire-toxin forms a very hard, deep-seated lesion. The extreme stagnation causes severe pain. The presence of fever and chills reflects the fight between the body’s resistance and the pathogenic factor.
In this formula:
• Jin Yin Hua is used as chief. This pungent and cold herb can either clear heat-toxin or expel heat. This aromatic flower brings strong, sufficient but light and subtle actions and is crowned as the definitive herb for treating Yang-type Yong Yang syndrome in traditional Chinese medicine.
• The remaining herbs are used as deputies in the formula. They can enhance the ability of Jin Yin Hua to clear heat-toxin and cool the blood.
Commentary on strategies
This formula contains only five herbs. They concentrate on intensively clearing heat, removing toxin and cooling the blood. It is only used in a severe case of boils and carbuncles at the metaphase stage and for a short period of time.
Tou Nong San (Discharge Pus Powder) 
Source: Wai Ke Zheng Zong 
Composition
Huang Qi ( Astragali radix) 12 g
Dang Gui ( Angelicae sinensis radix) 6 g
Chuan Xiong ( Chuanxiong rhizoma) 3 g
Chuan Shan Jia ( Manitis squama)** 3 g
Zao Jiao Ci ( Gleditsiae spina) 5 g
Analysis of the formula
This formula can push toxin outward and discharge pus. It is used for treating an abscess that leads to a chronic process. The abscess is accompanied by localized pain, swelling, heat and production of pus but without signs of perforation. This is because the Qi is deficient and it is unable to push the toxin outward and discharge the pus. Instead, an abscess is formed under the skin. The accumulated toxin creates pain, swelling and heat.
In this formula:
• Huang Qi is used as chief. It can strongly tonify the Spleen-Qi and strengthen the muscles. It also strengthens the Defensive-Qi in order to push out the toxin and discharge the pus.
• This action is strongly enhanced by Dang Gui and Chuan Xiong, which activate the blood circulation and remove toxin in the blood. They are considered as deputies in the formula.
• Chuan Shan Jia and Zao Jiao Ci are used as assistants. Their strong and sharp action of breaking up obstruction in the collaterals accelerates perforation.
Commentary on strategies
This formula demonstrates strategies of how to assist body resistance to push out toxin and accelerate perforation so as to discharge pus. It is often used in the condition of chronic and recurrent abscess.
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, dry dampness and relieve heat-toxin in the San Jiao regions. It is used to treat metaphase Yang-type Yong Yang syndrome when there is high fever, irritability, furuncle or carbuncle with thick and greenish pus. 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 the chief to directly clear heat from the Heart. 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 heat from the Upper- and Lower-Jiao respectively.
• Zhi Zi also serves 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, there are only four herbs. Huang Lian focuses on clearing heat from the Heart, the organ of fire. Huang Qin and Huang Bai can clear heat in the Upper- and Lower-Jiao so as to enhance the ability of Huang Lian. Zhi Zi helps Huang Lian to drain the Heart-fire by promoting urination. These four herbs are all bitter and cold; however, as they enter different meridians and regions, they can completely remove the damp-heat from the entire body.
2. Yin syndrome
Manifestations
Main symptoms
Localized swellings without sign of perforation and having no clear border with the surrounding tissue, no distinguishing color change of the skin and without warm sensation or severe pain.
Secondary symptoms
Generalized pain of the body, tiredness and weakness, fear of cold or having chills, scanty pus which is thin and without odor, weeping skin ulcers, an open wound with a purple or pale color, deformation of joints and atrophy of muscles.
Tongue
Pale with a white coating.
Pulse
Deep and thready.
Associated disorders in western medicine
Lymphatic tuberculosis, tubercular joint disease, chronic osteomyelitis, rheumatoid arthritis, aseptic suppuration, cancer.
Analysis of the syndrome
This is known as Yin-type Yong Yang syndrome. The disorders not only influence skin, subcutaneous regions and muscles, but also the joints and bones, such as a syndrome called crane’s knee wind, which manifests as a swollen and painful knee joint with muscular atrophy of the upper and lower legs. Yin-type Yong Yang syndrome exists in the condition of Yang deficiency and blood deficiency. In such conditions, cold, dampness and phlegm can accumulate and congeal, with stagnant blood in muscles, tendons and bones.
• Since there is no obvious heat, the color of the skin is not changed. However, in a severe and chronic case, a purple color of the lesion can be observed. The color suggests chronic blood stagnation.
• In the absence of heat, which has a moving and expanding nature, the Yin-type Yong Yang lesion is not as painful and swollen, and has no clear border with the surrounding tissue.
• An open lesion is usually a chronic ulcer, which produces thin fluid or pus. This is because the body’s resistance is very weak and is unable to fight against the pathogenic cold and dampness. Since the Qi and blood are too weak to support growing flesh, the healing process is very slow.
• The pale tongue and thready pulse indicate the deficiency of the Qi and blood of the body.
(See Figure 19.2 on page 396.)
Treatment principle: Expel wind, cold and dampness, promote blood circulation, tonify the Qi and blood and strengthen the Yang
Herb selection principles and formula composition strategies
• First, herbs that are pungent and warm, and can expel dampness, wind and cold from the skin, subcutaneous region, muscles and meridians are selected, along with sweet and warm herbs that tonify the Qi, blood and Yang of the body.
• Second, herbs that are pungent and warm and can promote blood circulation are selected.
• At the recovery stage, herbs that tonify the Qi, blood and Yin are often selected.
Structure of the formula and selection of herbs
Chief: Expel wind, dampness and cold, warm the Yang and tonify the blood
Cang Zhu ( Atractylodis rhizoma) and Ai Ye ( Artemisiae argyi folium)
Cang Zhu is pungent, bitter and warm, and enters the Spleen and Stomach meridians. It is a strong aromatic herb and can reach the skin, subcutaneous region and muscles. Since it can effectively dry dampness and open up meridians, it can be used as chief in the formula to treat Yin-type Yong Yang disorder.
Ai Ye is pungent, bitter and warm, and enters the Liver, Spleen and Kidney meridians. This aromatic herb can regulate Qi and blood, warm meridians, expel cold and stop pain. It can be selected as chief in the formula to treat the cause of Yin-type Yong Yang disorder.
Gui Zhi ( Cinnamomi cassiae ramulus), Rou Gui ( Cinnamomi cassiae cortex) and Lu Jiao Jiao ( Cervi cornu gelatinum)**
Gui Zhi and Rou Gui are sweet and pungent. Gui Zhi enters the Heart meridian and Rou Gui enters the Kidney meridian. They warm the interior, strengthen the Yang of the Heart and Kidney respectively, and can expel cold. They can be used as chief in the formula to treat the cause of Yin-type Yong Yang syndrome.
Lu Jiao Jiao is also sweet and warm, and enters the Kidney and Liver meridians. It can warm the Kidney-Yang and tonify the Kidney-essence and the blood. Since it is an animal product, it has a stronger and quicker action of tonifying the body than that of herbs. It is selected as chief for treating the cause and pathological development of chronic Yin-type Yong Yang syndrome where the Yang, the Kidney-essence and the blood are severely weakened.
Shu Di Huang ( Rehmanniae radix praeparata), Dang Gui ( Angelicae sinensis radix) and Huang Qi ( Astragali radix)
Shu Di Huang is sweet and slightly warm, and enters the Liver and Kidney meridians. It can tonify the blood and Kidney-essence so as to treat the cause of Yin-type Yong Yang syndrome.
Having a similar function to that of Shu Di Huang, Dang Gui can also tonify the blood. In addition, it can promote blood circulation and improve the blood supply in the local region owing to its pungent nature. As Dang Gui enters the Liver meridian, it can particularly tonify the Liver blood and benefit the joints and tendons.
Huang Qi is sweet, and warm, and enters the Spleen and Lung meridians. This herb can strongly tonify the Spleen-Qi and ascend the Qi to the Lung. It can warm the muscles and strengthen and spread the Defensive-Qi in the subcutaneous region and skin. To treat Ying-type Yong Yang syndrome, Huang Qi can be used as chief in the formula at different stages to tonify the Lung-Qi and Spleen-Qi. In the initial period it can prevent the development of the disorder when the Qi is too weak to defend itself from pathogenic factors. It can be used at the chronic stage of Yong Yang syndrome where chronic ulcer is not healing when the Qi is too weak to push out the toxin and dampness. It can also be used in the recovery period when the body becomes very weak after a long-term illness and Qi and blood are severely consumed.
Deputy: Promote Qi movement and blood circulation, tonify Qi and blood, eliminate cold and dampness and open up meridians
Hong Hua ( Carthami flos), Tao Ren ( Persicae semen) and Chuan Xiong ( Chuanxiong rhizoma)
These herbs are pungent and warm. They enter the Liver and Heart meridians and can activate blood circulation and remove congealed blood. For treating Yin-type Yong Yang syndrome, these herbs can improve blood supply in the local region, help the body resistance to clean up dampness, remove the stagnation and promote healing. They can also relieve pain and stiffness of the muscles and joints.
Ji Xue Teng ( Spatholobi caulis et radix) and Sang Zhi ( Mori ramulus)
Ji Xue Teng is bitter, slightly sweet and warm, and enters the Liver and Kidney meridians. It can tonify the blood and promote blood circulation. As it is the vine of the plant, it has the function of opening up the meridians and collaterals. It can treat stiffness and numbness of limbs due to blood deficiency and blood stagnation. It can be used in the formula for treating Yin-type Yong Yang syndrome, especially when the muscles and joints are stiff and weak due to both deficiency and stagnation of blood.
Sang Zhi is bitter and neutral, and enters the Liver meridian. This herb can expel wind and dampness, promote urination, benefit joints and relax tendons. It can be used when the Yin-type swelling or ulcer is swollen up or weeping, and is slow to heal.
Jiang Huang ( Curcumae longae rhizoma), Ru Xiang ( Olibanum) and Mo Yao ( Myrrhae)
Jiang Huang is pungent and warm, and enters the Spleen and Liver meridians. It can strongly promote the Qi movement and blood circulation, and open up the meridians so that it can relieve pain. This herb can be used in conditions where there is deformation of joints with pain, stiffness and muscular atrophy of the limbs.
Ru Xiang is bitter, pungent and warm, and enters the Heart, Liver and Spleen meridians; Mo Yao is bitter, pungent and neutral, and enters the Liver meridian. Both can break up congealed blood, open up meridians and stop pain. Since they move quickly and can easily reach the skin, subcutaneous region and muscles, they are particularly suitable for selection in treating Yin-type swelling in bones and joints where deformation, pain and stiffness present. They can also be used to treat skin ulcers and open wounds that are dark-purple in color due to poor blood supply in the local area in a chronic condition. These herbs improve blood supply, stimulate growing of new flesh and promote healing.
Assistant: Tonify Qi, blood and Yin, promote healing of the ulcer
Huang Qi ( Astragali radix), Bai Zhu ( Atractylodis macrocephalae rhizoma) and Fu Ling ( Poria)
These herbs are often used as assistants in the formula to strengthen the function of the Spleen so as to dry dampness and promote healing of Yin-type Yong Yang syndrome. Huang Qi also has the function of stimulating the growing of new flesh and promoting healing.
Sheng Ma ( Cimicifugae rhizoma), Bai Zhi ( Angelicae dahuricae radix) and Fang Feng ( Saposhnikoviae radix)
Sheng Ma enters the Spleen meridian and has an ascending nature. It is often used together with Huang Qi to enhance its function of ascending the Spleen-Qi and strengthening the muscles in order to stimulate the growing of new flesh and promote healing in Yin-type Yong Yang syndrome.
Bai Zhi is pungent and hot, and enters the Spleen meridian. This aromatic herb can spread its Qi quickly and can penetrate turbidity, transform dampness and discharge pus and fluid. It is often used as assistant in the formula when the Yin-type ulcer discharges thin and turbid pus and fluid, and healing is not able to take place.
Fang Feng is pungent and slightly warm, and enters the Spleen meridian. It can expel wind and dampness and can be selected as assistant in the formula to treat Yin-type ulcer where fluid, pus and swelling present.
Tian Men Dong ( Asparagi radix), Mai Men Dong ( Ophiopogonis radix), Lu Gen ( Phragmitis rhizoma), Bai Shao Yao ( Paeoniae radix lactiflora) and Zhi Gan Cao ( Glycyrrhizae radix preparata)
Except for Zhi Gan Cao, all these herbs are sweet and cold. They can nourish the Yin of different organs of the body. Tian Men Dong primarily enters the Kidney meridian, Bai Shao Yao the Liver meridian, Mai Men Dong the Heart and Stomach meridians, and Lu Gen the Lung meridian. If these herbs are combined with Zhi Gan Cao, the tonifying function becomes stronger and stable. They can be used as helping assistants in the formula to treat Yin deficiency when Yin is not used properly but turns into accumulated fluid, dampness or pus in a chronic Yin-type ulcer.
Since the pungent and warm herbs that are used in the formula can also injure the Yin of the body, the sweet and cold herbs can be used as corrective assistants to nourish the Yin and reduce the side effects of the pungent and warm herbs.
Envoy: Harmonize herbs in a formula
Sheng Gan Cao ( Glycyrrhizae radix)
Sheng Gan Cao is sweet and neutral. It can harmonize the herbs in the formula and also reduce toxin. This herb is used in small amounts because its sweet taste may preserve dampness.
Examples of classical formulas
Yang He Tang (Yang-Heartening Decoction) 
Source: Wai Ke Quan Sheng Ji 
Composition
Shu Di Huang ( Rehmanniae radix praeparata) 30 g
Lu Jiao Jiao ( Cervi cornu gelatinum)** 9 g
Pao Jiang (quick-fried Zingiberis rhizoma preparatum) 2 g
Rou Gui ( Cinnamomi cassiae cortex) 3 g
Ma Huang ( Ephedrae herba)* 2 g
Bai Jie Zi ( Sinapis albae semen) 6 g
Sheng Gan Cao ( Glycyrrhizae radix) 3 g
Analysis of the formula
This formula can warm the Yang and tonify the blood, expel cold and treat Yin-type swelling or ulcer. The manifestations are localized swelling without signs of perforation, no clear border with surrounding tissues, no distinguishing color change of the skin and without warm sensation or severe pain. This formula treats Yin-type ulcer, which produces fluid and thin pus and is slow to heal. The patient has a pale tongue with a white coating and a deep and thready pulse.
In the formula:
• The sweet and warm Shu Di Huang is used to tonify the essence and blood of the body, together with Lu Jiao Jiao to tonify the Kidney-essence and Yang, and strengthen the bones and tendons. When the blood and Yang are strong, the Qi is strengthened, the dampness can be reduced and the healing process can start.
• Pao Jiang and Rou Gui are used as deputies to gently and steadily spread the Yang and warm the muscles so as to expel the dampness and cold. Pao Jiang is processed Sheng Jiang ( Zingiberis rhizoma recens). After processing, the pungent nature of Sheng Jiang is reduced. As it can gently warm the Middle-Jiao and strengthen the Spleen, it can warm the muscles and activate blood circulation to improve the local condition. Rou Gui is pungent but its sweet taste reduces its pungent property. It can warm the Kidney-Yang so as to stimulate the Qi, Yang and blood in the local region.
• Ma Huang is pungent and hot, and enters the Lung meridian. It can activate the Qi movement and lead the herbs entering the affected area in the superficial region of the body. Bai Jie Zi is also pungent and hot. It can expel dampness and cold, and remove phlegm, particularly in the subcutaneous region. They are used as assistants in the formula.
• Sheng Gan Cao is used as envoy to harmonize the herbs in the formula and to reduce toxin.
Commentary on strategies
In this formula, a number of warm herbs are used.
• One group contains warm and sweet Shu Di Huang, Lu Jiao Jiao and Rou Gui to tonify the Yang, essence and blood, promote the growing of flesh and promote healing.
• Another group contains hot and pungent Ma Huang and Bai Jie Zi. They can activate the Yang, expel cold and eliminate dampness and phlegm. When they are used together, Yin-type localized swelling can be treated.
• Moreover, this formula also suggests that using animal products may quickly and strongly tonify the Yang, blood and essence. In clinical practice, an appropriate diet with chicken, mutton and venison is suggested.
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| Figure 19.1 •. |
| Etiology and pathology of Yang type Yong Yang syndrome. |
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| Figure 19.2 •. |
| Etiology and pathology of Yin type Yong Yang syndrome. |
