Commonly Used Formulas For the Treatment of Mental Disorders

by Heiner Fruehauf

he concept of an inseparable bodymind continuum is one of the main characteristics of Eastern thought. In classical Chinese medicine, therefore, mental activity has always been considered to be inseparable from bodily functions, and mental diseases were generally not treated differently from any other disorder. The Chinese term 'yuzheng' (depression), for instance, refers to stagnation on both a physical and mental plane, and is usually addressed with the same diagnostic and therapeutic means as diseases that would be considered to have entirely physical origins in the West. It is perhaps this absence of a body/mind dichotomy that is at the core of Chinese medical theory and practice. As described in the classic sources of Chinese scientific thought, such as the Yijing (Book of Change), the Daodejing, or the Neijing (Inner Canon of the Yellow Emperor), ancient Chinese observers of life always postulated the existence of a primordial One. From this prenatal entity, they thought, emerged two polar aspects which interact in a process of constant flux. This concept that all differentiation originates from a single source is one of the main messages of the Daodejing, the Taoist text which first coined the classic statement: "The Dao produced the One, the One produced the Two, the Two produced the Three, and the Three produced the Myriad Things." Every thing and every phenomenon, according to Chinese medical theory, can be analysed with this one-two-threemany grid of categorisation. In the one space time continuum we live in, for instance, there are the two dominant celestial bodies sun and moon, surrounded by myriads of other stars; there is humankind as a whole, differentiated into male and female; and there is the individual human being, consisting of material form (body) and immaterial qi which in its highest form is called 'shen' - the conscious mind. Although most scholars and practitioners of Chinese Medicine agree that the body (xing) and the mind (shen) are interdependent entities, there has been much discussion about the concrete nature of this relationship. In the People's Republic of China, discussions of this nature are often influenced by political considerations. Most mainland scholars, acutely aware of the Marxist agenda of their superiors, usually draw a distinct line between religious 'idealists' and scientific 'materialists' when it comes to body/mind related topics. Xunzi, the ancient philosopher who had said that "when there is a body, there can be a mind," has been hailed in contemporary books as a model of "materialist MENTAL DISORDERS by Heiner Fruehauf and thus scientific" thinking1. This increasing emphasis on the structural aspects of the body, however, goes back much further than the establishment of the People's Republic of China in 1949. If we take a look at Chinese medical history, it becomes evident that a gradual shift from the immaterial yang aspects to the structural yin aspects of diagnosis and treatment has been taking place throughout the last two millennia. In the original source texts of Chinese medicine, represented by the Book of Change, the Daodejing, and the Inner Canon, yin and yang are depicted as equal forces, yet the rising yang stands out as the conceptual landmark from which the various phases of the cyclical process of transformation are assessed. According to the Inner Canon, for instance, the energetic network that is referred to as the Heart governs the activities of all other organs: "The Heart is the ruler of all the other organ systems, and it is here that the power of the conscious mind is created. If the ruler is bright, there will be peace below ... If the ruler is dim, however, the twelve organ systems will enter a state of crisis, resulting in channel obstruction and severe injury to the physical body.2". Following the formative period of Chinese medicine, a gradual yet obvious shift of attention toward the structural (yin jing) aspects of the body occurred. Diagnostic procedure, for instance, changed from sensing the shen, i.e. the energetic glow of the face and eyes (Inner Canon, c.200 B.C.) to the more hands-on yet still qi oriented method of pulse palpitation (Shanghan Lun, c.200 A.D.), to a primarily structurally oriented system where tongue shape and col-our (18-19th century) or X-ray pictures (PRC) are the main means of diagnosis. The same is true for the therapeutic realm where the ancient and entirely qi based modalities of qigong and acupuncture were gradually replaced by herbal medicine, a system that is based on the administration of material substances. Within the developing field of herbal medicine moreover, the early emphasis on yang herbs such as Rou Gui (Cortex Cinnamomi Cassiae) and Fu Zi (Radix Aconiti Carmichaeli Praeparatae) gave way to a growing preference for yin herbs such as Di Huang (Radix Rehmanniae Glutinosae), or dense jing tonics derived from animal materials. But no matter what school of thought they adhere to, scholars of Chinese medicine usually agree that the mental and physical aspects of the human body are engaged in a process of constant movement and transformation. Any physical process is believed to have mental implications and vice versa. The connecting entity is qi, which can be differentiated into physical and mental qi only academically. In general, mental energy (shen qi) is simply regarded as a more refined form of physical energy (jing qi). Traditional treatment principles for mental diseases, therefore, do not fall outside the realm of standard diagnostic and therapeutic procedure. Even in contemporary China, mental patients usually visit doctors who specialise in "internal medicine," that is the treatment of organ disorders with Chinese herbs, minerals, and animal materials. The therapeutic focus tends to be on the restoration of uninhibited qi flow, since unbalanced emotions first affect the qi before they influence the physical structure of the body. Since chronic qi stagnation eventually results in the formation of structural pathologies such as blood stasis or phlegm coagulation, the modalities of blood moving and phlegm purging are standard methods to treat the more chronic types of mental disorders. In addition, Chinese physicians often address various types of deficiencies. The following is a brief overview of traditional and contemporary approaches to the most common mental disorders. In classic Chinese medical texts, depression is labelled yuzheng (depression syndrome) and refers to a wide array of symptoms which are usually attributed to stagnant qi. Unhappy emotions are generally believed to be the prime cause for stagnant qi. This psychosomatic aspect of qi has been emphasised in sources that go back at least as far as the Inner Canon, which pioneered the classic statement "In a patient full of grief and sadness, the qi becomes depressed and does not move"3. Later on, the 7th century medical compendium, Zhubing Yuanhou Lun (A Discussion of the Symptoms and Origins of Disease), devoted an entire subchapter to the pathogenesis and treatment of 'knotted qi', explaining that "the knotted qi disease is caused by grief and worry."4 The term 'yu' describes symptoms of mental depression and maybe the beginning stages of physical manifestation, such as discomfort in the sides of the body or the sensation of a lump in the throat. At a more advanced stage, it can incorporate severe symptoms of phlegm and blood stagnation such as tumours or other types of accumulations which have formed due to a chronic state of imbalance. Since the traditional Chinese concept of health is closely tied to the presence of an uninterrupted energy flow, depression - the manifestation of obstructed or 'depressed' qi flow - has always been taken very seriously by Chinese physicians. Several influential medical scholars even asserted that all disease has its origin in the depression of the mental and physical flow continuum. The Song dynasty physician Chen Yan, in his landmark work, Sanyin Ji Yi Bing Zheng Fang Lun (Discussion of Illnesses, Patterns, and Formulas Related to the Unification of the Three Aetiologies), first singled out the depression of the seven emotional affects (joy, anger, anxiety, worry, grief, apprehension, and fright) as a major aspect of clinical pathology. This theory culminated in the formation of an entire school of medical thought, represented by the six depression approach (depression of qi, blood, dampness, phlegm, fire, and food) authored by the 15th century physician Zhu Danxi. Zhu created the influential statement "If qi and blood exist in abundance and harmony, a person will not get sick. Once there is depression, all kinds of diseases will start to evolve. Therefore, all of the body's diseases are caused by depression5." From this rich tapestry of medical thought and clinical experience evolved a prolific reservoir of herbal formulas that are frequently used in the treatment of depression. Not surprisingly, most of these formulas regulate various aspects of the Liver network. The Liver is in charge of the harmonious distribution of qi - the flow organ of the human body/mind complex; as the Chinese pictogram for Liver indicates, it strives to spread upward and outward and resents being suppressed. The Liver channel, moreover, runs deep through the sexual organs, and another area associated with the realm of the subconscious - dream activity - is generally attributed to the Liver network. All of these factors indicate the close conceptual affinity of the Liver system to the hidden realm that Western culture accesses through psychotherapy. "All depression," the 18th century primer Zabing Yuanliu Xizhu (Wondrous Lantern Peering into the Origin and Development of Miscellaneous Diseases) thus declares, "can be classified as a Liver disease. The origin of this disorder is excessive worrying."6 'Yu' (depression), in other words, is a general term for diseases that have originally been caused by emotional problems. It is primarily a qi disorder, and is generally treated as such. After a long time, however, 'qi depression' may cause a) blood stasis, b) fire depression, c) damp depression, d) phlegm depression, or e) various levels of deficiency. Treatment strategies for chronic depression thus may have to take these components into account. Here are some of the most common traditional formulas which are still frequently used for the treatment of depression in contemporary Chinese hospitals and clinics: ¥ Xiao Chai Hu Tang (Minor Bupleurum Decoction): relieves shaoyang, harmonises the surface and the interior, realigns the Liver and Spleen. Typical symptoms include a bitter or metallic taste in the mouth, dry throat, blurred vision, restlessness, poor appetite, alternating hot and cold sensations, intercostal or subcostal distress, nausea, and a fine and wiry pulse. ¥ Da Chai Hu Tang (Major Bupleurum Decoction): harmonises shaoyang, purges internal heat accumulation. Typical symptoms include a sensation of alternating cold and heat, lateral chest pain, a bitter or metallic taste in the mouth, nausea, subcostal fullness and pain, constipation, restlessness, a greasy yellow tongue coating, and a deep and wiry pulse. ¥ Si Ni San (Frigid Extremities Powder): realigns the Liver and Spleen. Typical symptoms include distention, pain, or a stuck feeling in the Stomach, lower abdominal, or intercostal regions; a mild coldness of the hands and feet when getting nervous or stressed, constipation or a sensation of unsatisfactory bowel movement or diarrhoea accompanied by tenesmus, dry or swollen eyes, and a slippery Liver/ Gallbladder pulse. ¥ Xiao Yao San (Rambling Powder): soothes the Liver and relieves stagnation, strengthens the Spleen and nourishes blood. Typical symptoms include poor or irregular appetite, intercostal distress, menstrual pain and/or pre-menstrual breast distention, sensation of fullness in the epigastric region, general fatigue, a flushed face, and a fine and wiry pulse. ¥ Ban Xia Hou Po Tang (Pinellia and Magnolia Bark Decoction): disperses stagnant qi and accumulation, dissolves phlegm, restores the downward movement of Stomach qi. Typical symptoms include plumpit syndrome (a subjective feeling of something being stuck in the throat) or a dry itching or piercing pain in the throat, a stuffy feeling in the chest and epigastric region, digestive symptoms (nausea, belching, poor appetite, gurgling sounds in the epigastric region); secondary symptoms may include localised swelling, insomnia, or coughing. ¥ Yue Ju Wan (Escape Restraint Pill): moves qi and resolves depression of qi, blood, phlegm, fire, damp, or food. Typical symptoms include stuffiness in the chest and diaphragm regions, intercostal distress, distention or pain in the epigastric or abdominal regions, acid belching, poor appetite, irregular bowel movements, a wiry and slippery pulse, and possibly nausea or vomiting. ¥ Gan Cao Xiao Mai Da Zao Tang (Licorice, Wheat, and Jujube Decoction): nourishes the Heart and quietens the spirit, relaxes tension and harmonises the Stomach. Typical symptoms include frequent crying, hysterical behaviour, loss of self-control, unfocused mind, overly self-conscious behaviour. Secondary symptoms may include tight abdominal muscles, insomnia or restless sleep, frequent yawning, and forgetfulness. ¥ Bai He Di Huang Tang (Lily and Rehmannia Decoction) or Bai He Zhi Mu Tang (Lily Combination): clears yin deficiency heat in the Heart and Lung, boosts qi, and quietens the spirit. Typical symptoms include an unusually wide variety of subjective symptoms, unstable emotions, poor focus, unclear goals, unclear sensation of temperature ("sometimes I am too hot, but then again, sometimes I really feel more cold"), dizziness, a metallic taste in the mouth, red tongue, yellow urine, and a rapid pulse. At the Institute for National Medicine and Pharmacology in Heilongjiang Province, Dr. Ma Longqi used a combination of the traditional shaoyang formulas Xiao Chai Hu Tang (Minor Bupleurum Decoction), Da Chai Hu Tang (Major Bupleurum Decoction) and Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction), to treat 307 patients who had been officially diag nosed as suffering from 'neurasthenia', a term that is frequently used in China to describe depression. The formula he used, Ningshen Lingfang(Calm the Spirit Magic Formula) consisted of Chai Hu (Radix Bupleuri) 20g, Huang Qin (Radix Scutellariae Baicalensis) 15g, Ban Xia (Rhizoma Pinelliae Ternatae) 15g, Long Gu (Os Draconis) 20g, Mu Li (Concha Ostreae) 20g, Da Huang (Rhizoma Rhei) 7.5g, Gan Cao (Radix Glycyrrhizae Uralensis) 10g, and Gui Zhi (Ramulus Cinnamomi Cassiae) 15g. The formula was decocted, spray dried, and administered in granulated form. At the end of the study a general effectiveness rate of 96.7% was reported, with a markedly improved rate of 56%7. In Western clinical practice, the diagnosis and treatment of mental disease tends to be highly differentiated. Chinese physicians, however, have often discussed the various manifestations of mental disease under the same heading. Nonetheless, treatment strategies are complex, mostly consisting of the three aggressive methods of purging, flushing phlegm, and moving blood. Due to the obvious discrepancy between the modern and the traditional assessment of mental disease, contemporary Chinese researchers appear to be divided about the best way of conducting scientific clinical trials in this field. Some have opted to set up their trials according to Western diagnosis, accepting only cases that have been officially diagnosed as suffering from obsessional neurosis, or psychogenic psychosis, or schizophrenia. Others have opted to conduct their clinical studies according to their own clinical experience, using a single "mental formula" for all kinds of disorders, including depression or schizophrenia which are discussed elsewhere in this article. The following case studies all focus on the generic approach to mental disease. • Wen Dan Tang (Warm the Gallbladder Decoction): rectifies qi flow and dissolves heat phlegm, clears the Gallbladder and harmonises the Stomach. Typical symptoms include stubborn insomnia, vivid dreaming, occasional palpitations, restlessness, stuffy feeling in the chest, bitter taste in the mouth, dizziness, a yellow and sticky tongue coating, and a slippery pulse. This is one of the representative formulas for heat phlegm. Since mental diseases are often diagnosed as phlegm obstructing the orifice of the Heart, it has evolved into one of the prime remedies for the treatment of mental and psycho neurotic diseases. In an early study, the formula was prescribed to 149 cases diagnosed with "mental disease;" 117 were reported cured, 2 markedly improved, 24 improved, and 6 showed no results8. In a more recent study, Wen Dan Tang was administered to 132 patients suffering from neurasthenia, menopausal syndrome, schizophrenia, or other mental disorders; at the end of the study, 41 were declared cured, 74 improved, while 17 showed no results. The overall effectiveness rate was assessed at 87%9. • Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction): courses the Liver and relieves depression, clears heat and purges fire. Typical symptoms include a stuffy feeling in the chest, a heavy and sinking feeling in the body, depression, insomnia, utterance of non-sensical gibberish, inhibited urination and digestive disturbances. This is a famous 'mental' formula which is particularly popular in Japan. In a relatively recent study, it was given to 35 cases with depression; 15 were reported cured, 10 markedly improved, 9 improved, and 1 showed no result10. In another study, the formula was prescribed to 54 cases with depression, and 36 cases with epilepsy; of the depressed patients, 32 were reported cured, 19 improved, and 3 showed no results; of the epileptic patients, 18 were declared cured, 11 improved, and 7 without results11. In a much earlier trial, the formula was combined withDiankuang Mengxing Tang (Awaken from the Dream of Mania Decoction) and administered to 40 schizophrenia patients; 10 were reported cured, 10 improved, and 20 showed no improvement12. ¥ Jieyu San (Relieve Depression Powder): This is a modern formula containing Chen Pi (Pericarpium Citri Reticulatae), Ban Xia (Rhizoma Pinelliae Ternatae), Zhi Qiao (Fructus Citri seu Ponciri), Zhu Ru (Caulis Bambusae in Taeniis), Zhi Zi (Fructus Gardeniae Jasminoidis), Hong Hua (Flos Carthami Tinctorii), Xiang Fu (Rhizoma Cyperi Rotundi), Shi Chang Pu (Rhizoma Acori Graminei), Shan Zha (Fructus Crataegi), Cang Zhu (Rhizoma Atractylodis), Sha Ren (Fructus seu Semen Amomi), Su He Xiang (Styrax), and Peng Sha (Borax). Ingredients are ground into a fine powder, and put into capsules containing 0.45g of herbal powder; patients are usually advised to take 4-8 capsules twice daily. This formula is primarily designed to treat the (excess) stasis aspect that is often present in mental disorders. It is said to be applicable for all kinds of mental diseases, including psycho neurosis, depression, schizophrenia, anxiety neurosis, psychogenic psychosis, obsessional neurosis, etc. In an experimental case study with 50 patients suffering from a variety of mental disorders, 16 were reported cured, 27 markedly improved, 6 improved, and 1 showed no result13. ¥ Xiao Yao San (Rambling Powder) [see above]: This formula is one of the most frequently prescribed formulas for milder degrees of mental disorder, including depression. Like the two previous formulas, it addresses the stasis aspect, but it also considers the beginning stages of deficiency. In one clinical trial, the formula was prescribed to 26 cases with affective psychosis; 16 were reported markedly improved, 7 improved, and 3 without result14 . There are many reports on the successful use of Xiao Yao San for the treatment of hysteria, including hysteric loss of voice15, hysteric blindness16 , and hysteric seizures17. Another study reported satisfying results for insomnia in neurasthenic patients18. Japanese physicians often use Jia Wei Xiao Yao San (Augmented Rambling Powder),the famous modification of the mother formula with Zhi Zi (Fructus Gardeniae Jasminoidis) and Mu Dan Pi (Cortex Moutan Radicis) added, to treat depression19. In Japan, it is also used as the standard formula for gastrointestinal neurosis, often in combination with Ban Xia Hou Po Tang (Pinellia and Magnolia Bark Decoction)20. A Chinese study reports that Jia Wei Xiao Yao San was prescribed successfully to patients with auditory hallucinations21. • Gan Cao Xiao Mai Da Zao Tang (Licorice, Wheat, and Jujube Decoction), [see above]: Due to its safety and high effectiveness, this classic formula has remained a favourite for the treatment of less serious mental disturbances, particularly if a soothing and nourishing rather than a dispersing effect is desired. Prime symptoms are crying and signs of mental aggravation. A study conducted in 1960 reports that the original formula was administered to 25 patients with an acute outbreak of hysteria; all 25 were reportedly cured22 . Due to an avalanche of successful trials conducted between 1958-60, Gan Cao Xiao Mai Da Zao Tang has become the first choice for the treatment of hysteria in contemporary PRC clinics. Since the amount of Gan Cao (Radix Glycyrrhizae Uralensis) is usually high (15g/day), side effects of oedema have been observed after prolonged intake; one study suggested counteracting this undesired affect by adding Fu Ling (Sclerotium Poriae Cocos) and He Huan Pi (Cortex Albizziae Julibrissin)23. The broad symptom complex referred to as 'neurasthenia' is another common indication for this formula. One trial used the original three food herbs licorice, jujube, and wheat to treat 34 cases with neurasthenia, and reported good results in 30 patients, while 3 patients failed to improve24. In another study, Gan Cao Xiao Mai Da Zao Tang plus Bai He (Bulbus Lilii) and Zhi Mu (Radix Anemarrhenae Asphodeloidis) was prescribed to 100 cases with neurasthenia; 28 patients reported that their headache and insomnia were cured, and 64 reported improvement25. Another trial added Bai He (Bulbus Lilii), Sheng Di Huang (Radix Rehmanniae Glutinosae) and Shou Wu Teng (Caulis Polygoni Multiflori) to the base formula and administered it to 110 cases; 12 were reported cured, 32 markedly improved, and 60 improved. Best results were reported for the insomnia symptoms (74.2%), while the total effectiveness rate was assessed at 100&. Other modifications of the formula include the addition of Bai He (Bulbus Lilii), Dang Shen (Radix Codonopsis Pilosulae), Long Chi (Dens Draconis), Hu Po (Succinum) and Wu Wei Zi (Fructus Schisandrae Chinensis), which was given to 94 cases with neurasthenic insomnia; 87 patients reported good results. The author of the study recommends that this modified version of the formula can be used for all kinds of deficiency related insomnia or other symptoms of yang flare-up, particularly if accompanied by symptoms of dizziness, palpitations, or memory loss27. Since 1959, there have been at least 8 reports in major Chinese medical journals concerning the use of Gan Cao Xiao Mai Da Zao Tang for schizophrenia28. In combination with Long Gu (Os Draconis) and Mu Li (Concha Ostreae), for instance, the formula was used to treat 79 cases with different types of schizophrenia who were not responding to any other medication. After taking the formula for 7-70 days, along with small amounts of chlorpromazine (maximum of 200 mg/day), 5 were reported cured, 23 markedly improved, 34 improved, and 17 without results. The markedly improved rate was assessed at 35.5). In another study, Dr. Cheng Menxue combined Gan Cao Xiao Mai Da Zao Tang with Bai He Gu Jin Tang (Lily Bulb Decoction to Preserve the Metal) to treat 146 schizophrenia patients who were not responding to Western psychopharmacopoeia (117 of the patients also took 200mg of chlorpromazine per day); after taking the formula for 7-98 days, with an average of 16.8 days, 11 were reportedly cured, 44 markedly improved, and 64 improved. The general effectiveness rate was assessed at 81.40. In two other recent trials, the formula was successfully used to treat 133 cases suffering from menopausal syndrome; hot flashes were reduced in 94.4% of patients, sweating in 84.1%, insomnia in 92.7%, headaches in 86.8%, dizziness in 67.8%, restlessness in 70.2%, and abdominal distention in 751. There have also been several reports about the use of this formula for the treatment of epilepsy in children32 . Other trials reported that the formulas was useful in the treatment of somnambulism and globus hystericus (plumpit syndrome). Schizophrenia has always been looked upon as a 'strange' disease by Chinese physicians. Over the last hundred years, many self-declared masters of difficult diseases have taken up the challenge. Among them were Wang Qingren, the 19th century renegade physician and representative of the clinically extremely important blood moving school, and Zhang Xichun, the eminent 1920's physician who was known for his phlegm oriented approach to difficult diseases. Wang designed yet another blood moving formula for the treatment of schizophrenia, namely Dian Kuang Meng Xing Tang (Awaken from the Dream of Madness Decoction), while Zhang created Dang Tan Tang (Flushing the Phlegm Decoction). By primarily addressing phlegm and blood stasis, both of these approaches are representative of the traditional treatment of schizophrenia and 'strange disorders' in general. In traditional texts, schizophrenia is usually referred to as 'madness syndrome' (dian kuang). This term is ambiguous, since it really includes two opposite conditions, namely dian (depression) and kuang (mania, wild and crazy behaviour). Kuang often refers to the violent eruption of a mental condition, which usually can be controlled rapidly by the application of purging methods33. The high status of purging methods among the therapeutic modalities of Chinese medicine reflects the ancient concept of an evil spirit possessing the patient, which needs to be aggressively expelled from the body. Schizophrenia, however, is a complex disorder which can have a multiplicity of causes. Prolonged purging, favoured in many contemporary Chinese case studies, is thus not necessarily the correct treatment for patients who have been diagnosed with schizophrenia by a Western physician. The contemporary manual, Xiandai Zhongyi Neike Xue (A Modern Handbook of TCM Internal Medicine), appropriately emphasises the necessity of broadly distinguishing between the categories of yang type schizophrenia and yin type schizophrenia, that is between the 'wild' manic type and the depressed type. Yang type schizophrenia is characterised by symptoms of hallucinations (auditory, olfactory, or visual hallucinations; discussions with imaginary partners), delusions (paranoia, jealousy, hate, guilt, religious delusions etc.), bizarre behaviour (strange clothing, strange movements, tendency to attack others, repetitious speech or actions), and irregular thought patterns (answers do not match questions, sentences are not logically connected, constant change of topics, etc.). The base formula suggested in the manual is a modified version of Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction) consisting of Chai Hu (Radix Bupleuri) 15g, Long Gu (Os Draconis) 60g, Mu Li (Concha Ostreae) 60g, Ban Xia (Rhizoma Pinelliae Ternatae) 15g, Tao Ren (Semen Persicae) 30g, Hong Hua (Flos Carthami Tinctorii) 15g, Chi Shao (Radix Paeoniae Rubrae) 30g and Da Huang (Rhizoma Rhei) 30g, to be taken daily for 60-90 days. Yin type schizophrenia is characterised by symptoms of dull emotional expression (no change in facial expression, dull eyes, decrease in self-initiated movements, inability to love etc.), reduced intellectual activity (talks little, sentences have little content or are unfinished, slow response), and decrease of general awareness (lack of hygiene, loss of concentration, decreased sex drive, loner behaviour, low excitability, disregard of social codes). The suggested base formula is a modified version of Si Ni Jia Gui Tang (Frigid Extremities Decoction plus Cinnamon Twig), consisting of Fu Zi (Radix Aconiti Carmichaeli Praeparatae) 60g, Gan Jiang (Rhizoma Zingiberis Officinalis) 30g, Rou Gui (Cortex Cinnamomi Cassiae) 15g, and Gan Cao (Radix Glycyrrhizae Uralensis) 15g, to be taken for 60-90 days. Despite the high dose of Fu Zi (Radix Aconiti Carmichaeli Praeparatae), no side effects were observed in extended clinical trials34. Both of these approaches are characterised by their heavy usage of either Fu Zi (Radix Aconiti Carmichaeli Praeparatae) or Da Huang (Rhizoma Rhei), both of which, due to their pharmacological force, are otherwise rarely used in amounts exceeding 10g. Due to the traditional proverb that "special diseases should be addressed with special methods", this tendency of shocking both body and mind out of their highly disturbed state is quite common in contemporary clinical practice. One of China's leading schizophrenia specialists, Dr. Qiao Yuchuan, prescribed the following formula to 415 schizophrenia patients: Shi Gao (Gypsum) 155g, Da Huang (Rhizoma Rhei) 62g, Sheng Tie Luo (Frusta Ferri) 31g, Meng Shi (Lapis) 31g, Ye Jiao Teng (Caulis Polygoni Multiflori) 31g, Huang Qin (Radix Scutellariae Baicalensis) 24g, Huang Bai (Cortex Phellodendri) 24g. The herbs were boiled three times to yield a total of 2,000 ml of medicinal fluid which, divided into six portions, was imbibed at two hour intervals. The standard treatment time was two weeks, with an expected occurrence of diarrhoea that was not to be treated. After two weeks, the prescription Gui Pi Tang (Restore the Spleen Decoction) or other harmonising formulas was advised. Of 415 participating patients, 330 were reported cured, 42 improved, 2 without result, and 41 stopped the treatment before completion. The overall effectiveness rate was 98.65. In a consecutive study conducted by the same research team employing three differentiations of this formula (Schizophrenia Formula No.1 for depressed Liver qi and fire flare-up, Schizophrenia Formula No.2 for blood deficiency and phlegm fire, and Schizophrenia Formula No.3 for excess heat in the yangming channels), similar results were achieved. Of 500 patients (229 males, 271 females, all ages, disease histories ranging from several months to 30 years), 401 were reported cured, 93 improved, and 6 without result36 . The modern term anxiety disorders encompasses a group of mental illnesses in which symptoms of anxiety prevail. Anxiety disorders are fairly common, affecting roughly four percent of the population in North America. Western medicine distinguishes between generalised anxiety disorder (anxiety neurosis), panic disorder, phobia, post-traumatic stress disorder, and obsessive-compulsive behaviour. All of these disorders involve the vegetative nervous system in an obvious manner. Patients tend to be extremely tense and nervous. During acute attacks involving fear and/or panic there may be breathing difficulties, palpitations, dizziness, nausea, abdominal distention, or a variety of other symptoms. Anxiety disorders are frequently accompanied by sleep disturbances such as insomnia or excessive sleeping. From a Chinese perspective, symptoms of anxiety always call for methods that 'quieten the spirit' (anshen, dingshen, ningshen). Almost all formulas designed for this disorder thus employ sedating materials, such as the downbearing minerals Ci Shi (Magnetitum) and Long Gu (Os Draconis). In addition, differentiated approaches are used to address the underlying cause for spirit unrest, such as blood deficiency or phlegm obstruction. Ning Shen Jie Lui Tang (Calm the Spirit and Resolve Anxiety Decoction), an experimental formula devised by Dr. Ding Fouting that was recently tried in a large scale study, illustrates the typical approach to anxiety neurosis in contemporary clinical practice. Note again the heavy dosages which are typical for the treatment of mental disorders. The base formula consists of Long Chi (Dens Draconis) 30g, Ci Shi (Magnetitum) 30g, Suan Zao Ren (Semen Ziziphi Spinosae) 15g, Yuan Zhi (Radix Polygalae Tenuifoliae) 15g, Shi Chang Pu (Rhizoma Acori Graminei) 15g, Yu Jin (Tuber Curcumae) 24g, Gan Song (Rhizoma Nardostachytis) 12g, He Huan Pi (Cortex Albizziae Julibrissin) 9g, Gan Cao (Radix Glycyrrhizae Uralensis) 9g, Hu Po (Succinum) 3g and Zhu Sha (Cinnabaris) 3g (the last two ingredients to be taken in powdered form). The base acupuncture point prescription accompanying the herbal treatment was Fengfu DU-16, Baihui DU-20, Tongli HE-5, Shenmen HE-7, and Neiguan P-6. Common differentiations addressing the underlying constitutional imbalance included the following: ¥ Liver qi stagnation: plus Bai Shao (Radix Paeoniae Lactiflorae) 24g, Xiang Fu (Rhizoma Cyperi Rotundi) 24g, Chai Hu (Radix Bupleuri) 18g, Qing Pi (Pericarpium Citri Reticulatae Viride) 12g and Gan Cao (Radix Glycyrrhizae Uralensis) 9g. Acupuncture therapy: plus Ganshu BL-18 and Xingjian LIV-2. ¥ Phlegm obstruction: plus Zhi Shi (Fructus Citri seu Ponciri Immaturus) 12g, Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 12g, Xiang Fu (Rhizoma Cyperi Rotundi) 12g, Dan Nan Xing (Rhizoma Arisaematis cum Felle Bovis) 9g, Fu Ling (Sclerotium Poriae Cocos) 15g, Ban Xia (Rhizoma Pinelliae Ternatae) 15g, Fu Hai Shi (Pumice) 30g, Meng Shi (Lapis) 30g, and Su Ye (Folium Perillae Frutescentis) 5g. Acupuncture therapy: plus Feishu BL-13, Hegu L.I.-4, Lieque LU-7, Tiantu REN-22 and Fenglong ST-40. ¥ Heart blood deficiency: Yuan Zhi (Radix Polygalae Tenuifoliae), Shi Chang Pu (Rhizoma Acori Graminei) and Yu Jin (Tuber Curcumae) were decreased to 9g each, Suan Zao Ren (Semen Ziziphi Spinosae) was increased to 30g plus Dang Shen (Radix Codonopsis Pilosulae) 30g, Dang Gui (Radix Angelicae Sinensis) 30g, Wu Wei Zi (Fructus Schisandrae Chinensis) 30g, Long Yan Rou (Arillus Euphoriae Longanae) 30g, Fu Shen (Poriae Cocos Pararadicis Sclerotium) 15g, Mai Men Dong (Tuber Ophiopogonis Japonici) 15g, and Da Zao (Fructus Zizyphi Jujubae) 15g. Acupuncture therapy: plus Xinshu BL-15 and Pishu BL-20. ¥ Blood stasis: plus Dan Shen (Radix Salviae Miltiorrhizae) 30g, Tao Ren (Semen Persicae) 15g, Hong Hua (Flos Carthami Tinctorii) 15g, Chi Shao (Radix Paeoniae Rubrae) 15g, and Shui Zhi (Hirudo seu Whitmaniae) 15g. Acupuncture therapy: plus Xuehai SP-10 and Geshu BL-17. Of the 266 cases participating in the study, all were reported cured. After one year, 211 remained without reoccurrence, 31 reported reoccurences and had to repeat the treatment, and 24 died of unrelated diseases37. Insomnia is probably the most frequent symptom accompanying neurotic disorders. In Chinese medicine, it is again the sedating aspect which plays a predominant role in clinical therapy. A modern formula, Zhen Xin An Shen Tang (Sedate the Heart and Calm the Spirit Decoction), was used for 157 cases with sleeping disorders. All participating patients reported one of the following symptom complexes: extreme difficulty in falling asleep, less than three hours of sleep per night, loss of effectiveness of sleeping pills; or waking up early without being able to go back to sleep, sleeping only 2-3 hours a night, or inability to fall asleep at all during the night. The formula used was a combination of ingredients that are primarily known for their sedating affect: Long Gu (Os Draconis) 10-30g, Mu Li (Concha Ostreae) 30g, Fu Ling (Sclerotium Poriae Cocos) 12g, Ye Jiao Teng (Caulis Polygoni Multiflori) 30g, Dan Shen (Radix Salviae Miltiorrhizae) 30g, Chao Suan Zao Ren (Fried Semen Ziziphi Spinosae) 30g, He Huan Pi (Cortex Albizziae Julibrissin) 12g. Patients were instructed to boil the materials twice, take the weaker medicinal liquid obtained from the second boiling in the afternoon or in the evening, and drink the first boiling right before going to bed. If there was a tendency to wake up early, patients were advised to take the first boiling before going to bed, and the second boiling after waking up. After 3 days of treatment, progress in the 157 participants was evaluated in the following way: 98 markedly improved, 55 improved, and 4 without results38. A similar approach was employed by the designers of a herbal sleeping pill, which was formulated at the height of Chinese-Western combination therapy during the late 1970's. The experimental Anmian Wan (Sleeping Pills) contained equal amounts of Chuan Xiong (Radix Ligustici Wallichii), Suan Zao Ren (Semen Ziziphi Spinosae), Zhi Mu (Radix Anemarrhenae Asphodeloidis), Hu Po (Succinum), Bai Shao (Radix Paeoniae Lactiflorae), He Huan Hua (Flos Albizziae Julibrissin), Mu Li (Concha Ostreae), Long Gu (Os Draconis), Bai He (Bulbus Lilii) and Zi Su Ye (Folium Perillae Frutescentis). Ingredients were ground into a fine powder and manufactured into honey pills weighing 3g each. Patients were advised to take 2-3 pills one hour before going to sleep. Of 453 cases, the treatment was considered effective (the patient could sleep within 30-60 minutes of taking the pills) in 361 patients, and not effective in 92 patients39. Since Wang Qingren's contribution to Chinese medicine, there has been a heightened awareness of the role of blood stasis in chronic diseases. Contemporary Chinese clinicians thus put great emphasis on blood moving herbs such as Dan Shen (Radix Salviae Miltiorrhizae) and formulas such as Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction) in the treatment of insomnia. In 1986, Dr. Xie Yong et. al. published his experience with the blood moving approach to insomnia in the article, 'A Report of Treating 240 Insomnia Cases With Blood Movers.' The base formula tested consisted of Dan Shen (Radix Salviae Miltiorrhizae) 20-45g, San Leng (Rhizoma Sparganii) 20-45g, Xiang Fu (Rhizoma Cyperi Rotundi) 10-25g, Mu Xiang (Radix Saussureae seu Vladimirae) 10-25g, Dang Gui (Radix Angelicae Sinensis) 10-25g, and Zhi Zi (Fructus Gardeniae Jasminoidis) 10-20g. Typical modifications were: for neurosis, plus He Huan Pi (Cortex Albizziae Julibrissin) 10-20g, Ye Jiao Teng (Caulis Polygoni Multiflori) 10-20g, and Zhen Zhu Mu (Concha Margaritaferae) 25-40g; for schizophrenia, plus Meng Shi (Lapis) 30-50g, Mu Li (Concha Ostreae) 30-50g, Long Gu (Os Draconis) 30-50g, and Hu Po (Succinum) 6-15g; for obvious headache, plus Chuan Xiong (Radix Ligustici Wallichii)10-20g and Chai Hu (Radix Bupleuri) 10-15g; for general deficiency, plus Dang Shen (Radix Codonopsis Pilosulae) and Huang Qi (Radix Astragali). Of 240 cases (115 males, 125 females; 120 neurosis patients, 120 schizophrenia patients; disease histories ranging from 3 months to 15 years, with an average of 3 years), 81 were reported markedly improved, 87 improved, and 72 without satisfying results. The treatment period was 20 days. The best effects were observed in neurasthenic patients40. Another example for this approach is the experimental research formula,Huo Xue Mian Tong Tang (Move the Blood and Bring About Sleep Formula). It contains San Leng (Rhizoma Sparganii) 10g, E Zhu (Rhizoma Curcumae Zedoariae) 10g, Chai Hu (Radix Bupleuri) 10g, Zhi Gan Cao (Radix Glycyrrhizae Praeparatae) 10g, Bai Shao (Radix Paeoniae Lactiflorae) 10g, Bai Zhu (Rhizoma Atractylodis Macrocephalae) 10g, Suan Zao Ren (Semen Ziziphi Spinosae) 12g, Dang Gui (Radix Angelicae Sinensis) 15g, Dan Shen (Radix Salviae Miltiorrhizae) 15g, Fu Ling (Sclerotium Poriae Cocos) 18g, Ye Jiao Teng (Caulis Polygoni Multiflori) 24g, and Zhen Zhu Mu (Concha Margaritaferae) 30g. The remedy was tried on 112 patients suffering from severe insomnia, which was defined as only 1-3 hours of sleep per night, accompanied by symptoms of dizziness/headache, memory loss, panicky emotional state, shortness of breath or fatigue. At the end of the study, 30 were reported cured, 45 markedly improved, 29 improved, and 8 without result. The general effectiveness rate was assessed at 93%. The shortest treatment time was 1 week, the longest 8 weeks, with an average of 3 weeks41. The following is a more detailed discussion of many of the formulas discussed in the article above. The focus is on their application and modifications in the treatment of mental disorders, and their many other applications are not discussed. Chai Hu Jia Long Gu Mu Li Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction) Ingredients Chai Hu (Radix Bupleuri) 12g Huang Qin (Radix Scutellariae Baicalensis) 5g Da Huang (Rhizoma Rhei) 6g Ban Xia (Rhizoma Pinelliae Ternatae) 9g Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 5g Ren Shen (Radix Ginseng) 5g Da Zao (Fructus Zizyphi Jujubae) 5g Gui Zhi (Ramulus Cinnamomi Cassiae) 5g Fu Ling (Sclerotium Poriae Cocos) 5g Long Gu (Os Draconis) 5g Mu Li (Concha Ostreae) 5g Therapeutic principles:courses the Liver and relieves depression, clears heat and purges fire. Symptoms and signs: stuffy feeling in the chest, heavy and sinking feeling in the body; depression, easily startled, insomnia, utterance of non-sensical gibberish; inhibited urination; digestive disturbances (constipation, subcostal pressure and bloating, etc.). Pulse: wiry and rapid, possibly deep and forceful. Tongue: tends to be reddish, with no or yellow coating (especially towards the back). Indications: epilepsy, depression, schizophrenia, neurotic insomnia; cardiac neurosis; drug withdrawal syndrome (nicotine, caffeine, valium, etc.); baldness. Discussion of ingredients: Chai Hu disperses shaoyang pathogens (located between interior and surface); Huang Qin clears internal heat, particularly Gallbladder heat and upper burner heat; Da Huang purges internal fire and relieves constipation; Ren Shen and Da Zao strengthen and protect the Spleen; Ban Xia, Fu Ling and Sheng Jiang eliminate nausea by harmonising the Stomach and drying dampness and phlegm; Gui Zhi and Fu Ling stimulate water metabolism and disinhibit urination; Mu Li and Long Gu sedate the shen. Discussion: this prescription first appeared in the classic formula source book, Shanghan Lun. It is a famous modification of Xiao Chai Hu Tang (Minor Bupleurum Decoction), with a specific focus on mental disorders such as epilepsy, schizophrenia, or severe depression. Since the original formula includes lead, a potent yet toxic sedating agent, the formula is now rarely used in China. In Japan, however, where a no-lead version of Chai Hu Jia Long Gu Mu Li Tang has been approved by the Ministry of Health, the formula is prescribed very frequently. A variety of modern usages have been reported by Japanese doctors, including the stimulation of hair growth in bald people (treatment periods ranging from two to six months). Da Chai Hu Tang (Major Bupleurum Decoction) Ingredients Chai Hu (Radix Bupleuri) 15-24g Huang Qin (Radix Scutellariae Baicalensis) 9g Bai Shao (Radix Paeoniae Lactiflorae) 9g Zhi Shi (Fructus Citri seu Ponciri Immaturus) 9g Da Huang (Rhizoma Rhei) 6g Ban Xia (Rhizoma Pinelliae Ternatae) 9-15g Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 12-15g Da Zao (Fructus Zizyphi Jujubae) 9g Preparation: the herbs are decocted; the time at which the Da Huang is added, as well as its dosage (see modifications), will influence the potential laxative action of this formula. Therapeutic principles: harmonises shaoyang (the region between the surface and the interior); purges internal heat accumulation. Symptoms and signs: • Shaoyang (Liver/Gallbladder) pattern, with sensation of alternating cold and heat, stuffy or painful feeling along the sides of chest, bitter taste in the mouth, incessant nausea and vomiting. ¥ Yangming (gastrointestinal) excess syndrome, with subcostal fullness and pain that resists palpation, constipation or extremely putrid diarrhoea, asthmatic breathing, restlessness. Tongue: yellow or grey coating (may be greasy). Pulse: sunken, wiry, and forceful. Discussion of ingredients: Chai Hu and Huang Qin harmonise the shaoyang; Da Huang and Zhi Shi purge internal heat accumulation; Bai Shao counteracts pain, and in combination with Chai Hu realigns the Liver; Ban Xia and Sheng Jiang harmonise the Stomach and ease vomiting; Da Zao moderates the formula's purgative action. Indications and adjustments: Mental diseases, such as depression, neurasthenia, psychoneurosis, insomnia. ¥ For mental diseases with obvious phlegm symptoms, add Yu Jin (Tuber Curcumae) and Ming Fan (Alum). ¥ For mental diseases with symptoms of stagnant blood, add Tao Ren (Semen Persicae) and Gui Zhi (Ramulus Cinnamomi Cassiae). ¥ If constipated, use Da Huang heavily (6-10g); if not constipated, use Da Huang lightly (3-6g). Cautions: This formula is indicated for use in persons of strong constitution. Da Huang may cause abdominal cramping or diarrhoea in some individuals. When the primary symptoms have been resolved, the formula may be changed to complete the therapy, or discontinued. Discussion: Da Chai Hu Tang was first recorded in the classic Han Dynasty compendium Shanghan Lun. It was specifically designed for patients suffering from both shaoyang (Liver/Gallbladder) and yangming (gastrointestinal) symptoms. Therefore, the formula is essentially a combination of the representative remedies for shaoyang syndrome (Xiao Chai Hu Tang) and yangming syndrome (Xiao Cheng Qi Tang). The formula is usually administered for intense abdominal pain caused by acute problems of the Gallbladder or pancreas. The range of its applications, however, is quite wide, making it a general formula for digestive system diseases. In Japan, physicians are known to prescribe considerably less Da Huang than their Chinese colleagues. The moderated version of the formula has broadened the general indications of Da Chai Hu Tang to include obesity, atherosclerosis, herpes, infertility, diabetes, and a variety of other diseases. However, even in Japanese usage, the typical patient profile requires a strong constitution. Ban Xia Hou Po Tang (Pinellia and Magnolia Bark Decoction) Ingredients Ban Xia (Rhizoma Pinelliae Ternatae) 12-15g Hou Po (Cortex Magnoliae Officinalis) 9g Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 9-15g Zi Su Ye (Folium Perillae Frutescentis) 6g Fu Ling (Sclerotium Poriae Cocos) 12g Preparation: The herbs are decocted; Zi Su Ye should be added late to avoid loss of essential oils. Therapeutic principles: Disperses stagnant qi and accumulation, dissolves phlegm, restores the downward movement of Stomach qi. Symptoms and signs: Subjective feeling of something being stuck in the throat ("can't spit it out, can't swallow it down") or dry itching or piercing pain in the throat. Agitation symptoms such as nervousness, anxiety, depression, insomnia. Stuffy feeling in the chest and epigastric region; coughing. Digestive symptoms such as nausea, belching, poor appetite, gurgling sounds in the epigastric region. Localised swelling; soft, non-painful. Tongue: swollen, with moist white or thick white coating. Pulse: sunken and weak. Discussion of ingredients: Ban Xia restores the downward movement of digestive qi, dries phlegm, and resolves accumulation. Hou Po restores the downward movement of digestive qi and dries dampness. Zi Su Ye perfuses Lung qi and eases the Liver by moving depressed qi. Sheng Jiang disperses stagnated water, and in combination with Ban Xia counteracts nausea. Fu Ling leeches out moisture and strengthens the Spleen. Indications and adjustments: ¥ For plumpit syndrome accompanied by general depression, combine with Xiao Yao San (Rambling Powder); for structural changes in the throat, add She Gan (Rhizoma Belamcandae Chinensis) and Shan Ci Gu (Bulbus Shancigu); for polyp of vocal cord, combine with Mai Men Dong Tang (Ophiopogonis Decoction). ¥ Mental disorders, such as anxiety, neurosis, hysteria, depression, schizophrenia (if accompanied by throat discomfort); for nerve related problems without productive coughing, add Da Zao (Fructus Zizyphi Jujubae); this will produce Si Qi Tang (Four-Ingredient Decoction for the Seven Emotions). ¥ Non-specific disorders, including chronic fatigue, dizziness, vertigo, palpitations, stuffiness in the chest, cold feet, gurgling sounds in the digestive tract; gastrointestinal neurosis. ¥ Hyperthyroidism; may add Xia Ku Cao (Spica Prunellae Vulgaris), Bai Shao (Radix Paeoniae Lactiflorae) and Xiang Fu (Rhizoma Cyperi Rotundi). Typical modifications ¥ For deficiency conditions, add Ren Shen (Radix Ginseng), Gui Zhi (Ramulus Cinnamomi Cassiae), Huang Qin (Radix Scutellariae Baicalensis) and Gan Cao (Radix Glycyrrhizae Uralensis), or add only Ren Shen (Radix Ginseng) and Gan Cao (Radix Glycyrrhizae Uralensis). This will produce Hou Po Sheng Jiang Ban Xia Gan Cao Ren Shen Tang (Magnolia Five Combination) with Zi Su Ye (Folium Perillae Frutescentis) and Fu Ling (Sclerotium Poriae Cocos) added. Cautions: In some texts, both Ban Xia and Hou Po are said to be contraindicated during pregnancy; however, this refers to raw Ban Xia and a high dosage of Hou Po. Discussion: Ban Xia Hou Po Tang first appeared in the classic formula compendium, Essentials from the Golden Cabinet (Jingui Yaolue). It was listed in the chapter on gynaecological disorders, and specifically recommended for "women who feel like there is a lump of baked meat stuck in their throat." Later generations have labelled this disorder 'plumpit syndrome' (meihe qi), a term that specifically refers to a lump-in-throat sensation which typically worsens when unhappy or depressed. Historical commentators have remarked that this enigmatic yet common problem is by no means limited to women, although clinical reports reveal that it is mostly female patients who seek therapy. Some scholars speculate that it might have been the repressed state of women in feudal Chinese society which fostered a disproportionately high occurrence of female laryngopharyngeal paresthesia at the time. Ban Xia Hou Po Tang has been the representative remedy for non-structural lumps in the throat since the 10th century, when the source book - originally part of the 1800 year old Shanghan Zabing Lun - was rediscovered in the imperial library. Xiao Chai Hu Tang (Minor Bupleurum Decoction) Ingredients Chai Hu (Radix Bupleuri) 15-24g Huang Qin (Radix Scutellariae Baicalensis) 9g Ren Shen (Radix Ginseng) 9g Gan Cao (Radix Glycyrrhizae Uralensis) 6g Da Zao (Fructus Zizyphi Jujubae) 9g Ban Xia (Rhizoma Pinelliae Ternatae) 9g Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 6g Therapeutic principles: relieves shaoyang, harmonises the surface and the interior, realigns the Liver and Spleen. Symptoms and signs: shaoyang symptom complex (bitter taste in the mouth, dry throat, blurred vision); restlessness; depression and poor appetite; distention in the sides of the body; alternating hot and cold spells; intercostal and subcostal distress; nausea; cyclic onset of symptoms. Pulse: fine and wiry (particularly on the left hand), possibly deep, but never strong. Tongue: thin white tongue coating or no coating. Indications: nervousness, irritability, depression, insomnia, and other mental disorders (particularly if related to the female menstrual cycle); pre-menstrual syndrome; narcotic analgetic withdrawal syndrome; epilepsy. Discussion of ingredients: Chai Hu disperses shaoyang pathogens (located between the interior and the surface); Huang Qin clears internal heat, particularly Gallbladder and upper burner heat; Ren Shen, Da Zao, and Gan Cao strengthen and protect the Spleen; Ban Xia and Sheng Jiang eliminate nausea by harmonising the Stomach and drying dampness and phlegm; Gan Cao co-ordinates the effects of cooling and warming herbs. Discussion: Xiao Chai Hu Tang (Minor Bupleurum Decoction) has traditionally been regarded as the representative formula of the so called harmonising method. It was first introduced in the Shanghan Lun as the definitive treatment for shaoyang disorders, but has since evolved to become one of the most frequently prescribed Chinese formulas of all times. Shaoyang disorders are said to occur in the dividing space between the surface and the interior, and are generally recognised by the signs outlined in the rubrics. Since the (shaoyang) triple burner meridian governs the circulation of fluids throughout the entire body, the symptom complex associated with this formula is very wide and can involve all of the three burning spaces. Modern scholars have linked the 'half inside/half outside' nature of shaoyang diseases to the lymph system, while others have related it to the fluid-containing layer of protective tissue surrounding the internal organs. Typically, symptoms occur along the (shaoyang) Gallbladder channel, and at pivotal body positions such as the throat, the subcostal region, or the inguinal region. Although the popularity of Xiao Chai Hu Tang is in part related to its reputation as a safe and 'harmless' remedy, many doctors have warned that it should only be prescribed when there is clear evidence of a shaoyang symptom complex. However, Zhang Zhongjing, the original author of the formula, pointed out that "not all of the defining symptoms have to be there at the same time; one of them will suffice." Si Ni San (Frigid Extremities Powder) Ingredients Chai Hu (Radix Bupleuri) 18 Bai Shao (Radix Paeoniae Lactiflorae) 15g Zhi Shi (Fructus Citri seu Ponciri Immaturus) 15g Gan Cao (Radix Glycyrrhizae Uralensis) 6g Therapeutic principles: realigns the Liver and Spleen. Symptoms and signs: distention, pain, or a stuck feeling in the Stomach, lower abdominal, or intercostal regions; a mild coldness of the hands and feet; constipation or a sensation of unsatisfactory bowel movement, diarrhoea accompanied by tenesmus; dry, swollen eyes. Tongue: thin white coating, or white/yellow and greasy coating. Pulse: wiry and slippery, particularly in Liver/Gallbladder position on the left hand. Indications: disturbance of the vegetative nerve system, depression, mental diseases. Discussion of ingredients: Chai Hu and Bai Shao relieve the Liver (Chai Hu disperses stagnant Liver qi, Bai Shao nourishes Liver blood); Chai Hu and Zhi Shi realign the Liver and Spleen by harmonising the physiological movements of ascending and descending qi (Chai Hu aids the ascent of Liver qi, Zhi Shi aids the descent of Spleen/Stomach qi); Bai Shao and Zhi Shi eliminate abdominal pain; Bai Shao and Gan Cao relax abdominal muscle spasms; Gan Cao strengthens the Spleen and harmonises the different effects of the herbs. Typical modifications: • For severe intercostal or abdominal pain, add Xiang Fu (Rhizoma Cyperi Rotundi), Qing Pi (Pericarpium Citri Reticulatae Viride) and Chuan Xiong (Radix Ligustici Wallichii). This will produce Chai Hu Shu Gan Tang. ¥ For greasy tongue coat accompanied by Stomach disorders, combine with Ping Wei San (Pacify the Stomach Powder). ¥ For expectoration of thick phlegm, add Gua Lou (Fructus Trichosanthis). Discussion: Si Ni San (Frigid Extremities Powder) was first introduced in the Shanghan Lun. Although most of the herbs used are cooling in nature, it was originally listed in the chapter on shaoyin (Kidney cold) syndrome. The remedy, therefore, should be understood as a footnote to the Kidney yang booster Si Ni Tang (Frigid Extremities Decoction), which essentially implies the warning that "Not every condition involving cold limbs (sini) is caused by an exhaustion of Kidney yang; this symptom can also be caused by damp heat obstructing the Liver/Gallbladder channels, in which case the condition should be treated with Si Ni San.". This is a good example of the classic approach of Chinese formula design, tackling serious diseases with a minimal and concise herbal arrow. Like other Chai Hu based remedies, Si Ni San can address a wide range of disorders involving all five organ networks, a fact which had already been stressed in the original text. Later generations of clinicians valued it as a versatile base formula that can be used as the core of a more complex prescription; some variations, such as Chai Hu Shu Gan San (Bupleurum Powder to Spread the Liver) or Xue Fu Zhu Yu Tang (Drive Out Stasis from the Mansion of Blood Decoction) have become famous in their own right. For acute conditions all ingredients except Gan Cao should be used heavily, particularly if the formula is used in unmodified form. Xiao Yao San (Rambling Powder) Ingredients Chai Hu (Radix Bupleuri) 9g Bai Shao (Radix Paeoniae Lactiflorae) 9g Dang Gui (Radix Angelicae Sinensis) 9g Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 3g Bai Zhu (Rhizoma Atractylodis Macrocephalae) 9g Fu Ling (Sclerotium Poriae Cocos) 9g Bo He (Herba Menthae) 3-6g Gan Cao (Radix Glycyrrhizae Uralensis) 6g Therapeutic principles: soothes the Liver and relieves stagnation, strengthens the Spleen and nourishes the blood. Symptoms and signs: discomfort in the sides of the chest, depression, menstrual cramping and/or pre-menstrual breast distention, poor appetite, sensation of fullness in the epigastric region, general fatigue, flushed face. Pulse: fine and wiry. Tongue: thin white coating or no coating. Indications: hormonal imbalances; neurasthenia, insomnia, depression, thymogenic mental disease; migraine; pre-menstrual breast tenderness and other PMS symptoms. Discussion of ingredients: Chai Hu and Bo He restore the uninhibited movement of Liver qi and prevent heat buildup; Chai Hu and Bai Shao regulate Liver functions; Dang Gui relieves stagnant Liver blood; Dang Gui and Bai Shao nourish Liver blood; Bai Zhu, Fu Ling, and Sheng Jiang protect the Spleen and ensure proper fluid metabolism; Gan Cao tonifies the Spleen and harmonises herbal functions. Typical modifications: • For obvious Liver heat (red face, temper tantrums, dizziness, rapid pulse, heavy menstrual bleeding, pre-menstrual acne), add Zhi Zi (Fructus Gardeniae Jasminoidis) and Mu Dan Pi (Cortex Moutan Radicis). This will produce Jia Wei Xiao Yao San (Augmented Rambling Powder). Discussion: Xiao Yao San (Rambling Powder) is an extremely popular modification of the two classic Shanghan Lun formulas, Si Ni San (Frigid Extremities Powder) and Dang Gui Shao Yao San (Tangkuei and Peony Formula). It first appeared in the influential 11th century compendium, Imperial Grace Formulary of the Taiping Era (Taiping Huimin Heji Jufang). Commissioned by the Song dynasty ministry of health, the work was specifically designed for clinicians and is thus more concise than other important formula compendia. Rather than being a complete catalogue listing all Song prescriptions, it focuses on 800 formulas that were considered outstanding by most eminent physicians of the time. Xiao Yao San can be considered to be the most famous remedy listed in this work. Along with Xiao Chai Hu Tang (Minor Bupleurum Decoction), it is also the representative remedy of the so called harmonising method. Xiao Yao San is extremely safe to use, but treatment usually needs to be administered over long periods of time. In fact, the name of the formula alludes to the action of melting (xiao) structural signs of stagnation without harming the blood, much like the sun melts ice without diminishing the essence of water; it further refers to the effect of moving (yao) the qi without dispersing it, like an oar stirs up ripples in the water without harming its basic substance. Through this bilateral action of both tonifying and moving qi and blood, Xiao Yao San 'eases' the distressed Liver - the functional organ network which is responsible for so many everyday problems like depression, menstrual tension and pain, or stress related disorders. Wen Dan Tang (Warm the Gallbladder Decoction) Ingredients: Ban Xia (Rhizoma Pinelliae Ternatae) 9g Chen Pi (Pericarpium Citri Reticulatae) 9g Fu Ling (Sclerotium Poriae Cocos) 9g Zhu Ru (Caulis Bambusae in Taeniis) 15-18g Zhi Shi (Fructus Citri seu Ponciri Immaturus) 9g Sheng Jiang (Rhizoma Zingiberis Officinalis Recens) 6g Gan Cao (Radix Glycyrrhizae Uralensis) 6g Da Zao (Fructus Zizyphi Jujubae) 3g Therapeutic principles: rectifies qi flow and dissolves heat phlegm, clears the Gallbladder and harmonises the Stomach. Symptoms and signs: stubborn insomnia, vivid dreaming; occasional Heart palpitations; restlessness; stuffy feeling in the chest; bitter taste in the mouth or frequent regurgitation of phlegm or turbid sputum; dizziness. Tongue: red with yellow and sticky coating. Pulse: slippery. Indications: mental diseases (schizophrenia, manic depressive psychosis, reactive psychosis, involutional psychosis, obsessional neurosis, neurasthenia, dementia, including those involving hereditary factors); nervous system disorders (functional disturbance of vegetative nervous system, menopausal syndrome, epilepsy, migraine). Discussion of ingredients: this formula is made from the representative phlegm dissolving remedy, Er Chen Tang (Two Cured Decoction), by adding qi dispersing and heat clearing herbs. Ban Xia and Chen Pi dry dampness and dissolve phlegm. Ban Xia and Fu Ling dry dampness and move turbid materials downwards. Ban Xia and Sheng Jiang warm and harmonise the Stomach. Chen Pi and Zhi Shi disperse stagnant qi and dissolve phlegm. Zhu Ru clears heat and dissolves phlegm. Sheng Jiang, Da Zao, and Gan Cao fortify the Spleen and Stomach and harmonise the effect of the other herbs. Typical modifications: ¥ For obvious heat symptoms, add Huang Lian (Rhizoma Coptidis). This will produce Huang Lian Wen Dan Tang (Coptis Decoction to Warm the Gallbladder). ¥ For insomnia and palpitations, add Suan Zao Ren (Semen Ziziphi Spinosae) and Huang Lian (Rhizoma Coptidis). This will produce Wen Dan Tang (Bamboo and Hoelen Combination)42. ¥ For stubborn cases, further add Yuan Zhi (Radix Polygalae Tenuifoliae). ¥ For additional qi dispersing, phlegm resolving, heat clearing, and a mildly tonic effect, add Chai Hu (Radix Bupleuri), Xiang Fu (Rhizoma Cyperi Rotundi), Jie Geng (Radix Platycodi Grandiflori), Huang Lian (Rhizoma Coptidis), and Ren Shen (Radix Ginseng). This will produce Zhu Ru Wen Dan Tang (Bamboo and Ginseng Combination). ¥ For mental or nerve related symptoms related to phlegm (clogging the orifice of the Heart), add Ming Fan (Alum), Yu Jin (Tuber Curcumae), and a heavy dose of Shi Chang Pu (Rhizoma Acori Graminei). ¥ For stroke in obese individuals (slurred speech, no loss of consciousness), or epilepsy (if foaming, but no dark lips and cold extremities), add Dan Nan Xing (Rhizoma Arisaematis cum Felle Bovis), Ren Shen (Radix Ginseng), and Shi Chang Pu (Rhizoma Acori Graminei). This will produce Di Tan Tang (Scour Phlegm Decoction). ¥ For hysteria, neurasthenia, or psycho neurosis with Gallbladder fire, add Chai Hu (Radix Bupleuri) and Huang Qin (Radix Scutellariae Baicalensis). Discussion: The earliest version of Wen Dan Tang was recorded by the famous 7th century scholar-physician Sun Simiao in his prolific compendium, Thousand Ducat Formulas (Qianjin Yaofang). It was not until five centuries later, however, that the formula appeared in its present form in the influential Song dynasty medical treatise, Discussion of Illnesses, Patterns, and Formulas Related to the Unification of the Three Aetiologies (Sanyin Jiyi Bingzheng Fanglun). The formula is widely regarded as the representative remedy for resolving heat phlegm, yet its enigmatic label - Warm the Gallbladder Decoction - has caused some misunderstandings. Many commentators have remarked that considering its action, the formula should really be called Qing Dan Tang (Clear the Gallbladder Decoction). 'Warming,' rather than referring to an elevation of physical temperature, here primarily seeks to evoke the philosophical connotations of the Chinese term, 'wen.' According to traditional theory, 'wen' is the most balanced, neutral, and harmonious energetic state, referring to warm weather and foods/herbs with mildly warming properties alike. By clearing heat and turbidity from the 'store house of pure fluids and mellifluous atmosphere' (Gallbladder), the formula seeks to restore the ideal state of spring-like harmony and mental well being. In recent years, more than twenty standard variations of Wen Dan Tang have been recorded in Chinese and Japanese journals, treating an extremely broad variety of diseases. The key component for the appropriate use of this formula is phlegm, often the less visible kind which obstructs the internal orifices of the Heart and thus clouds the patient's mental faculties. Wen Dan Tang is therefore one of the prime remedies for the treatment of mental and psycho neurotic diseases. Dian Kuang Meng Xing Tang (Awaken from the Nightmare of Mania Decoction) Ingredients Tao Ren (Semen Persicae) 24g Chi Shao (Radix Paeoniae Rubrae) 9g Chai Hu (Radix Bupleuri) 9g Da Fu Pi (Pericarpium Arecae Catechu) 9g Xiang Fu (Rhizoma Cyperi Rotundi) 6g Qing Pi (Pericarpium Citri Reticulatae Viride) 6g Su Zi (Fructus Perillae Frutescentis) 12g Chen Pi (Pericarpium Citri Reticulatae) 9g Ban Xia (Rhizoma Pinelliae Ternatae) 6g Mu Tong (Caulis Mutong) 9g Sang Bai Pi (Cortex Mori Albae Radicis) 9g Gan Cao (Radix Glycyrrhizae Uralensis) 15g Therapeutic principles: purges blood stasis, moves stagnant qi, drains phlegm downwards, and harmonises the centre. Indications: manic

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Authorby Heiner Fruehauf

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