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Traditional Herb Formulas for Treatment of Shen Disorders
by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon
There are hundreds of herbal formulas useful for shen disorders among the vast collection of Chinese medical literature. However, a relatively small number of prescriptions have been handed down over time and collected into texts that are used for the study of Chinese medicine today. These formulas are the ones most likely to be used by physicians in China and the West, at least as a reference point for preparing an individualized prescription, but often as a prepared formula ready to administer.
The well-established formulas for treatment of shen disorders may be subdivided into three groups for purposes of analysis and discussion: those that focus on tonification therapy; those that combine qi regulating and tonification; and those that combine tonification, sedating, and orifice opening. By presenting these three groups, it is not intended to suggest that other combinations of therapeutic principles are to be avoided, but that these three reveal the characteristics of most traditional formulas used today for shen disorders. Four sample formulas have been selected for each category of prescription.
Tonification Formulas
Deficiency of qi and blood are considered underlying syndromes that make a person susceptible to a wide variety of disorders and diseases. Qi and blood fill the vessels to block entry of pathological influences and they nourish the organs to protect them from deterioration or harmful changes in structure and function. In addition, qi deficiency leads to insufficient raising of clear yang to the brain, reducing mental and sensory acuity, while blood deficiency leads to insufficient moistening of the internal organs, making them less receptive as a resting place for the associated spirit.
The concept of raising clear yang is important to mental function; it was described by Li Dongyuan in his famous text Pi Wei Lun (1). He noted that:
After water and grain enter the stomach, yang qi ascends. Fluids and qi enter the heart and penetrate the lungs to replenish the skin and hair and to disperse throughout the hundreds of vessels. The spleen receives qi from the stomach to irrigate the four limbs and nourish the qi and blood. If, on the other hand, the stomach is injured by improper food and drink and the spleen is damaged by being overwhelmed [taxation fatigue], they become deficient….Generally speaking, if the spleen and stomach are deficient and weak, yang qi is unable to grow and rise up….When the spleen is diseased, yang qi flows down to overwhelm the kidneys.
In particular, the yang qi ascends to the top of the head, converging at the point GV-20 (baihui; hundred convergences; and the meeting point for the six yang channels). Since the kidneys nourish the marrow and brain, the problem of failure of yang qi to flow upward and invigorate the brain is compounded by downward flow of yang qi inhibiting the kidney (thus weakening the kidney's nourishment of the brain). Tonifying the spleen qi and raising qi become important, particularly where the brain function appears impeded (slow thought, reduced sensory function, cloudiness, confusion, poor memory, etc.). The herbs ginseng and astragalus (usually with licorice) are used for this purpose. Other ingredients may be added to assist in raising yang qi, such as cimicifuga ( shengma ), which is not one of the tonic herbs.
In the following list of sample formulas, all have astragalus, ginseng, and licorice for tonifying qi, benefiting the spleen and heart, and raising clear yang. The formulas all contain constituents of the main qi tonic formula, Si Junzi Tang (Four Major Herbs Combination) and the main blood nourishing formula, Si Wu Tang (Tang-kuei Four Combination). Schizandra, an astringent herb, is listed among the nourishing sedatives, which is how it is often used today. Yiqi Congming Tang is a formula primarily used for sensory weakness (poor vision or hearing), but it also improves brain function more generally, so is included here.
Table 1: Tonification Formulas for Shen Disorders.
Ingredient type
Gui Pi Tang
Yi Qi Congming Tang
Ren Shen Yang Ying Tang
Yang Xin Tang
Tonify/Raise Qi
Astragalus
Si Jun Zi Tang
Ingredients Ginseng
Atractylodes
Hoelen
Licorice
Si Wu Tang
Ingredients Tang-kuei
Peony
Rehmannia
Cnidium
Nourishing Sedatives
Polygala
Zizyphus
Schizandra
Other Herbs
jujube, longan, saussurea, ginger vitex, cimicifuga, pueraria, phellodendron citrus, cinnamon twig fu-shen, biota, pinellia, cinnamon bark
Of these formulas, Gui Pi Tang is the best known and most widely used. Domei Yakazu (2) relays a summary of applications of this formula as described in Japanese literature:
1. It is a wonderful prescription used mainly to treat a spleen and heart that are exhausted and injured by excessive thinking and worrying, resulting in amnesia and reckless acts or destructive behavior.
2. For those with insufficient blood in the heart, or for intestinal wind and bloody stools; hematemesis, epistaxis, spermatorrhea, white turbid urine, or dripping and painful urination, or for the strong-willed deep thinkers who have withered, yellow complexions, the prescription has a miraculous effect.
3. It is used for women who are peevish and irritable, can't be satisfied by any man, and can't get what they want. This mental condition leads to jealousy and hostility, resulting in weak and depressed spleen and heart with the accompanying symptoms of reckless acts, palpitation, flare-up of weak fire, white dandruff, paralysis in the feet and hands, fondness of lying in bed, poor appetite, thirst, itching and feverish skin heat, body odor, and pain and swelling or leukorrhea in the genital area.
4. It has an excellent effect in treating all diseases of the female genitalia. For bleeding during coitus, add cimicifuga [ shengma ] and peony [baishao] to the formula [note: shengma raises qi and peony astringes blood, so this combination is intended to prevent the falling of blood].
5. It has a marvelous effect in curing the weakness in widows and virgins who are sexually frustrated and, as a consequence, suffer depression and anxiety.
In addition to these common concerns, Guipi Tang may be of interest for a modern application of aiding persons withdrawing from certain antidepressant drugs (SSRIs), as described in the Appendix.
Qi-Regulating Formulas
Bupleurum is one of the most important of the herbs for alleviating stagnation of liver qi associated with depression of the mind. All the formulas listed in the table below include this herb; other qi regulating ingredients are cyperus, citrus, and either chih-shih (immature fruit) or chih-ko (mature fruit), which are types of citrus fruits. As with the above mentioned tonic formulations, ingredients of Si Junzi Tang and of Si Wu Tang are included, because deficiency of qi and blood contributes to the stagnation syndrome affecting the liver.
Table 2: Qi-Regulating Formulas for Treating Shen Disorders.
Ingredient type
Xiao Yao San
Zhu Ru Wen Dan Tang
Yi Gan San
Chai Hu Shu Gan San
Regulate flow of Qi
Bupleurum
Cyperus
Citrus
Chih-shih
Si Jun Zi Tang
Ingredients Ginseng
Atractylodes
Hoelen
Licorice
Si Wu Tang
Ingredients
Peony
Cnidium
Other Herbs
ginger, mentha [add gardenia and moutan to form Jiawei Xiao Yao San] pinellia, ginger, platycodon, bamboo, coptis, Uncaria
Of these formulas, by far the most widely used is Xiao Yao San (Tang-kuei and Bupleurum Formula) and its modification Jiawei Xiao Yao San(Bupleurum and Peony Formula), made from the former by adding the heat clearing herbs gardenia and moutan. The central herb of Xiao Yao San is bupleurum (chai Hu), used to release the liver qi that is stagnated by emotion. According to the Bencao Jiuzhen of 1773 A.D. (3):
Bupleurum is used for the condition of heat entering the women's blood chamber....In some cases, one may use it during pregnancy or after delivery...bupleurum has a lubricating nature; it is an excellent herb to stimulate the passage of qi...in cases of heat accumulation and blocked passage, it should be assisted by tang-kuei and scute (huangqin).
Based on such descriptions, bupleurum has been especially used in treatments for women, mainly in the context of Xiao Yao San and its derivative prescriptions. Souhaku Asada, a famous Japanese physician quoted in an article on bupleurum prescriptions, indicates that bupleurum has "calming characteristics," removing irritation, arresting panic, and treating vertigo, dizziness, tinnitus, and hearing difficulties (4).
As C.S. Cheung describes bupleurum's function (5), "it dredges the liver and relieves congestion." The term "dredges" is particularly appropriate, because the Chinese concept is that the liver, especially when it has been disturbed by frustration (inexpressible anger), can tenaciously hold on to the qi that it is supposed to help circulate, and the qi needs to be released by some means. An important herb for treating stagnation with emotional depression is cyperus (xiangfuzi), which is notable for its pleasant and penetrating fragrance. However, during the past century, bupleurum has gradually taken on greater importance for this role. It is especially relied upon when there is a stagnation of circulation associated with both the liver and spleen. The spleen is said to distribute the qi and moisture from food, a function that is disturbed by anxiety and worry.
The liver is associated with the wood element, which corresponds with growing plants. It is said that young plants that are full of sap grow vigorously during the spring (the season associated with wood) and bend easily under the pressure of wind (the climatic condition associated with wood), bouncing back readily (bending and bouncing back mimics the xiao yao ideal of journeying and returning). On the other hand, when wood has become aged and dried, its growth is slowed and it is no longer able to bend in the wind; rather, it can easily break; it can also easily be burned by fire. To assure that the liver, as representative of the wood element, remains healthy and able to easily respond to stresses (such as emotional reactions), it needs to be moistened. Hence, in the formula Xiao Yao San , bupleurum is joined by tang-kuei and peony, two herbs that nourish the liver blood. These herbs prevent and even reverse a condition of liver dryness.
The spleen is associated with the earth element, corresponding to the soil in which plants grow. When the soil is well drained, it supports the health of plants. When the earth becomes too moist, it is no longer a healthy medium; instead, plants growing in such conditions yellow and wilt, and their roots may rot. The soil that is saturated with moisture can no longer drain additional moisture that falls as rain, so there are floods and damage. Therefore, by this analogy, to keep the spleen and liver healthy, the excess moisture must be drained, and this is accomplished in the formula Xiao Yao San with the moisture resolving herbs hoelen and atractylodes. In addition, the function of the spleen is invigorated by baked licorice, a sweet, tonifying herb.
The complete Xiao Yao San formulation is filled out with two other herbs as adjuncts: mentha, to aid in the dredging of the liver; and fresh ginger, to aid the function of the spleen. These two herbs are also used to resolve congestion at the body surface, a function to which bupleurum also contributes.
The most widely used modification of Xiao Yao San is Bupleurum and Peony Formula (Jiawei Xiao Yao San ; jiawei means added ingredients; literally, added flavors). The additions, gardenia (shanjizi) and moutan (mudanpi), both clear heat; gardenia is said to purge fire from the liver and drain damp-heat from the gallbladder, while moutan is said to clear heat from the blood. The accumulation of qi in the liver is a type of fire syndrome (excess of qi) and the dryness of liver wood that arises further fuels the development of fire. This modified version is one of the most frequently prescribed formulas in Japan, particularly for emotional disorders and "erratic complaints" experienced by women (one of the xue dao zheng conditions described in Chapter 6); it is commonly given for perimenopause and early stage of menopause. Dr. Wago Mitani presents Bupleurum and Peony Formula as the central treatment for climacteric syndrome (6), which he says is comprised of symptoms such as "lack of physical strength, anxiety, poor concentration, insomnia, lethargy, somatic instability, tendency toward fatigue, and mild fever." The formula is also frequently prescribed for treatment of viral hepatitis because of its beneficial effects on the liver. In several modern books about Kampo medicine, Jiawei Xiao Yao San is mentioned but the original Xiao Yao San is not.
The primary reason for selecting Jiawei Xiao Yao San is the finding of evident symptoms of heat and agitation that would call for the inclusion of moutan and gardenia. Such heat symptoms are mentioned in the traditional indications for Xiao Yao San , but the added herbs improve the treatment when those symptoms are more evident. This formulation addresses the condition of "conflict between heat and the blood," in which the well-nourished blood can restrain heat. In return, the well-directed heat circulates the blood and prevents it from stagnating. Jiawei Xiao Yao San is indicated when the blood is insufficiently nourished and the heat is agitated (alternately constrained or rushing out without direction); the blood and heat are in conflict rather than harmony.
In a review of uses of Bupleurum and Peony Formula (7), Yakazu Domei indicated that of 65 patients treated by this prescription in his clinic, 43 of them were cases of xue dao zheng. In his analysis, he mentioned that the formula is effective for "treating various female diseases and general nervousness and anxiety." He states that:
This formula is regarded as having the ability to adjust the irregularity of the autonomic nerves caused by the stagnation of liver qi and the ability to act as a tranquilizer. In addition to treating menopausal disturbances of weak conformations, the formula is widely used for treating irregular menses, the side effects of abortions and miscarriages, emotional distress caused by any salpingoplasty [gynecological surgery] or uterine disturbance, infertility, etc.
Another formula listed in Table 2 is Yigan San (Bupleurum Formula), which is indicated for fire in the liver meridian, producing symptoms such as tic, teeth-grinding, or neurotic behavior. In a review of this formula by Dr. Hong-yen Hsu (8) it is said that the formula "decreases tendency toward anger and irritability, and treats insomnia due to excitement and neurotic hypersensitivity...also indicated for those with poor nutritional habits, decreased tolerance to stressful situations, heightened sensitivity to mild mental and physical excitement, and lack of autonomic nerve coordination." The formula is given to adults as well as children (for whom it was originally designed) and said to treat, among other things, menopausal disturbance and xue dao zheng. According to Dr. Hsu, in Commonly Used Chinese Herb Formulas with Illustrations (13) if pinellia and citrus are added to Bupleurum Formula, that formula "is indicated for adults (especially those past middle age, either perimenopause or postmenopause) with obvious neuropathy [neurotic conditions]." Pinellia and citrus promote the function of the stomach and gallbladder and help to remove dampness and phlegm-mist that may lead to mental dysfunction.
Sedative Formulations
The formulas described below incorporate three treatment methods: tonification, sedating the spirit, and opening the orifices. Three of the formulas are modern patents (that have been available for several decades). Ingredients lists provided for patent remedies such as these should be interpreted with some reservations, as the manufacturers often do not disclose all ingredients. The other formula, Tianwang Buxin Dan, is a traditional prescription as well as a patent, so the ingredients of the former version are widely publicized, though they vary considerably among the texts. The first three formulas listed had included cinnabar until recently. Polygala, which serves both as a sedative and orifice-opening herb, is classified here with the orifice-opening group; each formula includes at least one other herb aimed at resolving phlegm mist (e.g., acorus, bamboo, platycodon). Hoelen and alpinia, which each appear in two of the formulas, aid in dispersing fluids and thus contribute to preventing development of phlegm-mist, but are listed separately.
Table 3: Sedative Brain-Nourishing Formulas
Ingredient type
Tian Wang Bu Xin Dan
Bu Nao Wan
Jian Nao Wan
Bai Zi Yang Xin Wan
Spirit-Sedating Ingredients
Biota
Zizyphus
Schizandra
Dragon Teeth
Succinum
Orifice Opening and Phlegm Clearing Ingredients
Polygala
Acorus
Bamboo
Platycodon
Blood and Yin Nourishing Ingredients
Tang-kuei
Lycium fruit
Ophiopogon
Rehmannia
Cistanche
Other Herbs
asparagus, ginseng, hoelen walnut, gastrodia, alpinia, arisaema ginseng, alpinia, salvia, gastrodia, dioscorea hoelen, scrophularia, licorice
Tian Wang Bu Xin Dan (Ginseng and Zizyphus Formula) is the best known of the prescriptions in this group. It is considered suitable for long-term therapy in treating chronic brain disorders, such as those that occur with aging. Bu Nao Wan (Cerebral Tonic Pills) is a modern patent remedy indicated mainly for poor memory and insomnia, and also used for anxiety, heart palpitations, and being easily frightened. Healthy Brain Pills (Jia Nao Wan) is a modern patent designed along the same lines as Cerebral Tonic Pills, and for the same indications. Bai Zi Yan Xin Wan (Biota Heart Nourishing Pills) is a patent remedy that represents a variation of the traditional Tian Wang Bu Xin Dan; numerous other factories produce their own sedative formulas in which they attempt to improve on this widely-used prescription.
The name Tian Wang Bu Xin Dan makes reference to the "King of Heaven" (tian = heaven; wang = king, ruler) and to the action of supplementing the heart (buxin), being prepared in the form of a large pill rolled in cinnabar (dan; without cinnabar, the preparation should be called simply a pill: wan). The formula was first recorded in the Shesheng Mipou (Secret Investigations into Obtaining Health) written by Hong Ji in 1638 A.D. There is a story explaining the formula's unusual name-that Hong Ji had a dream in which the Heavenly King visited him and gave him the formula. However, Tianwang Buxin Dan is actually a relatively simple modification of a much earlier prescription known to Hong Ji, Pingbu Zhenxin Dan, from the famous book of the Song Dynasty, Taiping Huimin Hejiju Fang.
The recipe for Tianwang Buxin Dan is reported in differing texts with markedly different proportions of ingredients. The herb described as the key herb of the formula, rehmannia, is present in proportions ranging from 8% to 32% of the total weight. Following is the recipe presented in Chinese Herbal Medicine: Formulas and Strategies (9), in which rehmannia makes up 31% of the formula:
Tian Wang Bu Xin Dan
Sheng Di Huang Rehmannia, raw 120 grams
Wu Wei Zi Schizandra 30 grams
Dang Gui Tang-kuei 30 grams
Tian Men Dong Asparagus 30 grams
Mai Men Dong Ophiopogon 30 grams
Ba Zi Ren Biota 30 grams
Suan Zao Ren Zizyphus 30 grams
Ren Shen Ginseng 15 grams
Dan Shen Salvia 15 grams
Xuan Shen Scrophularia 15 grams
Fu Ling Hoelen 15 grams
Yuan Zhi Polygala 15 grams
Jie Geng Platycodon 15 grams
The herbs are powdered and then made into honey pills, typically yielding a bolus of about 9 grams (about 2/3 herbs, 1/3 honey); this batch is enough for a two month supply at one pill twice per day. Until recently, these pills were rolled in cinnabar, which was one of the examples of why remedies from China were said to be contaminated with heavy metals (in this case, mercury). Now, the pills are made without it.
The formula has the primary function of nourishing yin and blood and clearing heat. Several herbs of the formula have mild sedative effects, including ginseng, salvia, schizandra, polygala, biota, hoelen, and zizyphus. The formula is indicated for those showing deficiency syndrome with dryness, such as dry stool, dry mouth, and little tongue coating, and with heat (tongue body is red, pulse is rapid), though it can be used more generally. It is probably best used in cases of insomnia with constipation and for those who feel warm at night (there may be night sweating); it is avoided in cases of diarrhea and for persons who tend to be cold. The effect of the herbs in Tianwang Buxin Dan have been described by C.S. Cheung as follows (10):
The principle of treatment is to moisten the yin, clear the heat, nurture the blood and calm the spirit. Raw rehmannia as the chief herb in the prescription, moistens the yin, clears heat, and prevents any disturbances of spirit by deficiency. Scrophularia, ophiopogon, and asparagus assist rehmannia in moistening the yin and clearing heat. Salvia and tang-kuei nourish the blood and nurture the heart. The heart spirit becomes calm when the blood of the heart is repleted. Ginseng and hoelen benefit the heart qi and calm the heart spirit; biota and polygala calm the heart and pacify the spirit. Platycodon functions to carry the other herbs upwards; cinnabar is used to coat the pills: both of them act as messengers to enter the heart.
APPENDIX 1: Gui Pi Tang and SSRI Withdrawal Syndrome
The problem of adverse reactions to withdrawing from the antidepressants known as selective serotonin reuptake inhibitors (SSRIs) is important to patients, especially since they already may suffer from problems of anxiety and fear which can exacerbate their concerns about symptoms that arise. A Chinese herbal therapy for this condition has not been established, but can be suggested from the typical symptoms of withdrawal. A listing of symptoms that have been repeatedly observed in patients withdrawing from SSRIs is arranged in the left column of the following table by general type, and paired with a potential TCM interpretation of the symptoms in the right column.
Table 4: SSRI Withdrawal Symptoms and their TCM Interpretations.
Symptoms Potential TCM Interpretation
Psychiatric
anxiety, crying spells, insomnia, irritability, agitation, mood lability, vivid or bizarre dreams, difficulty with concentration and memory Deficiency of blood affecting the liver and heart, with instability of shen andhun (spirit associated with the liver; especially affects dreaming). These symptoms may additionally correspond to qi deficiency and stagnation (liver/spleen disharmony or simple spleen weakness), so the total syndrome would involve qi and blood deficiency and qi stagnation, destabilizing the mind.
Neurologic
dizziness, lightheadedness, headache, paresthesia (electric shock-like tingling), vertigo Damp accumulation may produce all of these symptoms; insufficient rise of clear yang qi may also produce these symptoms.
Motor
dystonia (gait instability), tremor These symptoms may correspond to generation of internal wind, a condition which results from deficiency of liver blood.
Gastrointestinal
nausea, vomiting, diarrhea Accumulation of dampness is a possible cause; adverse flow of qi may occur (upward or downward flow contrary to normal flow).
Somatic
chills, fatigue, lethargy, myalgias, rhinorrhea, sweating Qi deficiency, along with impaired circulation of qi may cause these symptoms; dampness can contribute to all these symptoms.
Summing up the notes about TCM interpretation, the withdrawal syndrome may revolve around the problems of qi and blood deficiency, which may be accompanied by qi stagnation and dampness accumulation (and, in rare cases, also by internal wind). These deficiency syndromes of Chinese medicine are attributed primarily to the spleen (for qi) and liver (for blood); a Western interpretation of the same pattern might be a relative deficiency in serotonin availability or an imbalance of neurotransmitters that occurs when the drugs are removed.
Key herbs that might be considered for SSRI withdrawal syndrome based on the symptom analysis include:
Atractylodes (white atractylodes): tonifies qi, resolves damp
Peony (white peony): nourishes blood, vitalizes blood circulation
Tang-kuei: nourishes blood, vitalizes blood circulation
Zizyphus: nourishes liver and heart blood and clams shen
Saussurea: circulates qi, calms shen
Ginseng: tonifies qi, calms shen
Astragalus: tonifies qi, raises yang qi
Polygala: resolves phlegm, calms shen
Fu-shen or Hoelen: resolves damp, calms shen
Pinellia: resolves damp, lowers stomach qi
Citrus: resolves damp, circulates qi
A formula with these ingredients can be constructed from the traditional formula Gu Pi Tang, which includes most of the herbs. According to Giovanni Maciocia, who is widely respected for his knowledge of TCM, this formula is itself used for treating depression (11). He noted that: "The formula Guipi Tangtonifies spleen-qi and heart-blood and calms the mind: it is ideally suited to treat post-natal depression and insomnia. This formula is also recommended by Wu Qian in his Golden Mirror of Medicine for post-natal depression from worry, pensiveness, and sadness." The ingredients may be provided as a decoction (Guipi Tang ), dried decoction, or in tablet form (Guipi Wan). A typical powder preparation is (12):
Gui Pi San
(Ginseng and Longan Combination)
Ren Shen Ginseng 15 g
Huang Qi Astragalus 15 g
Long Yan Rou Longan 12 g
Fu Ling Hoelen 10 g
Bai Zhu Atractylodes 10 g
Dang Gui Tang-kuei 10 g
Suan Zao Ren Zizyphus 10 g
Yuan Zhi Polygala 10 g
Mu Xiang Saussurea 5 g
Zhi Gan Cao Licorice 5 g
Da Zao Jujube 5 g
Sheng Jiang Ginger 5 g
In China, codonopsis has been used in place of ginseng for several decades, but the original formula is with ginseng for rapidly restoring the spleen qi and calming the spirit. For those with a more significant level of "damp" syndrome (especially with digestive disturbance), one might add to Gui Pi Tang one of the following:
Er Chen Wan aka Citrus and Pinellia Combination (has citrus, pinellia, hoelen)
Si Jun Zi Tang aka Major Four Herbs Formula (has ginseng, atractylodes, hoelen)
Wu Ling San aka Hoelen Five Herb Formula (has atractylodes and hoelen)
Xiang Sha Liu Jun Zi Tang aka Saussurea and Cardamom Combination (has ginseng, saussurea, hoelen, atractylodes, citrus, and pinellia)
Xiao Yao San aka Tang-kuei and Bupleurum Formula (has hoelen, atractylodes, tang-kuei, and peony)
While there have not been studies providing clinical evidence for efficacy of Gui Pi Tang, or any of the herbs mentioned, to alleviate SSRI discontinuation symptoms, it is a characteristic of modern Chinese medicine practices to select herbs on the basis of symptom patterns, with the expectation of attaining some level of effect. The symptoms are understood to be a manifestation of an underlying imbalance, whether described in ancient terms (e.g., qi and blood deficiency) or modern terms (e.g., neurotransmitter release and reuptake). That imbalance generates symptoms via common mechanisms that can be affected by the herbs. Starting an herbal formula along with gradual drug dose reductions may prevent or minimize the withdrawal symptoms.
APPENDIX 2: Bupleurum and Dragon Bone Combination for Xue Dao Zheng
Two bupleurum-based prescriptions stand out in the literature related to xue dao zheng: Bupleurum and Peony Formula, which has already been discussed, and Bupleurum and Dragon Bone Combination (Chai Hu Jia Long Gu Mu Li Tang). Another formula mentioned less frequently is Bupleurum and Cinnamon Combination (Chai Hu Gui Zhi Tang), which has several herbs in common with Bupleurum and Dragon Bone Combination. In the book Commonly Used Chinese Herb Formulas with Illustrations (13) this latter formula is said to treat numerous symptoms, including a variety of emotional and neurological disorders-nervous exhaustion, neurotic behavior, irritability, and hysteria. The ingredients for Bupleurum and Dragon Bone Combination are:
Bupleurum and Dragon Bone Combination
Chai Hu Bupleurum 20%
Ban Xia Pinellia 12%
Fu Ling Hoelen 12%
Gui Zhi Cinnamon 8%
Huang Qin Scute 8%
Ren Shen Ginseng 8%
Mu Li Oyster shell 8%
Long Gu Dragon bone 8%
Sheng Jiang Ginger 8%
Da Huang Rhubarb 8%
This formula calms the spirit with ginseng, dragon bone, and oyster shell, resolves phlegm-dampness with pinellia, ginger, and hoelen, and purges fire with scute and rhubarb. In Commonly Used Chinese Herb Formulas with Illustrations, the formula is said to be useful for neurosis, hysteria, neurotic insomnia, climacteric disorders, neurotic palpitation, and neurotic impotence. Combining this with a formula for stagnant blood or for qi stagnation and phlegm accumulation is thought to help resolve xue dao disorders even more effectively. Bupleurum and Cinnamon Combination is produced by deleting hoelen, rhubarb, dragon bone, and oyster shell (all of which have sedative effects) and replacing them with peony, licorice, and jujube (which contribute an antispasmodic and analgesic action).
Yakazu Domei (14), described use of Bupleurum and Dragon Bone Combination for 65 of his patients. Many of these patients were being treated for neurosis (heart palpitations, neurasthenia, hysteria, and neurotic chest pains). He classified the applications of the formula as treating three conditions: flushing up of qi, stagnant water, and lower torso weakness. As to the first, he listed symptoms of chest distress, discomfort, palpitations, strange moods, irritability, insomnia, stiff shoulders, heavy headedness, headaches, vertigo, frequent napping, spasms, delirium, and mania. For stagnant water syndrome, he included the symptoms of generalized lassitude and body heaviness along with water retention, and for lower torso weakness, he referred to weak legs, low back pain, impotence, and cold feet. He further mentions that the formula is frequently used to treat "the complications of mental, emotional, and nervous distress."
According to Takahide Kuwaki (15), the xue dao syndrome (which he calls "nervous diseases and autonomic nervous disorders") is usually treated with:
...formulas containing descending herbs, which in this case could be called sedatives. Of these descending drugs, dragon bone and oyster shell containing formulas are most often used. The two major formulas containing dragon bone and oyster shell are Bupleurum and Dragon Bone Combination (Chai Hu Long Gu Mu Li Tang) and Cinnamon and Dragon Bone Combination (Gui Zhi Jia Long Gu Mu Li Tang).
He suggests that the first formula is given to more robust types and the second to obviously weakened patients. Bupleurum and Dragon Bone Combination was not included in Table 2 with the qi regulating bupleurum-base formulas nor with the sedative formulas that have ingredients like dragon bone and oyster shell because this formula does not quite fit the patterns described for those approaches. While it includes qi tonics (ginseng, jujube), the qi regulating herb bupleurum (but not others for that purpose), and the sedatives dragon bone and oyster shell, it lacks blood nourishing herbs (that would make it more suited to long-term use) and only has a small contribution towards the problem of phlegm mist (hoelen and pinellia, but no acorus or polygala, for example). It is most suited, in its standard form, for short term use.
APPENDIX 3: Formula for Plum Pit Qi Syndrome
Pinellia and Magnolia Combination (Ban Xia Hou Pu Tang) was presented in the Jingui Laoyue (16), a treatise composed at the end of the Han Dynasty (ca. 220 A.D.). The text includes this brief statement: "A woman who feels as if a piece of broiled meat is stuck in her throat should take Ban Xia Hou Pu Tang." This statement has been interpreted to mean that the woman is suffering from globus hystericus, the feeling of a lump (globus) resulting from hysteria (an emotional state of mind originally thought to be associated with the uterus). The Chinese later described the sensation as that of a plum pit caught in the throat. Its cause is attributed to the emotions coupled with stagnation of phlegm. In a Japanese report on treatment of 45 patients with abnormal sensations in the throat (sense of pressure, swelling, or, in most cases, something stuck in the throat), relayed by Dr. Hong-yen Hsu (17), 21 of the patients of "weak" constitution were given Pinellia and Magnolia Combination, while 13 patients of "firm" constitution were given Bupleurum and Dragon Bone Combination.
The applications of Pinellia and Magnolia Combination have been expanded to include both the sensation of a lump that is without obvious physical cause and also now for several physical disorders, such as esophageal spasms, hoarseness, or difficulty swallowing. In two recent studies conducted in Japan, the formula was proclaimed beneficial in treating swallowing difficulty in the elderly. It was used to improve the swallowing reflex in those who suffered from stroke (18) and difficulty swallowing as a result of progression of Parkinson's disease (19). The mechanism of its action in these cases remains to be established.
In modern Chinese texts, Pinellia and Magnolia Combination is classified with the qi regulating formulas, even though none of the herb ingredients are classified in the Materia Medica as having the primary property of being qi regulators. Rather, these ingredients help circulate both qi and moisture. A typical presentation of its ingredients and quantities is (20):
Pinellia and Magnolia Combination
Ban Xia Pinellia 12 g
Fu Ling Hoelen 12 g
Hou Po Magnolia 9 g
Sheng Jiang Fresh ginger 9 g
Zi Su Ye Perilla 6 g
From the traditional Chinese point of view, both magnolia bark and perilla leaf regulate the flow of qi moisture and these actions are attributed to their fragrant components that have a dispersing effect. These herbs alleviate the neurotic and depressive syndromes that lead to plum pit qi. The qi regulating formulas in general, and the ingredient perilla leaf in particular, are recommended in China for treatment of depression and anxiety. In a recent laboratory evaluation, Pinellia and Magnolia Combination was reported to have antidepressant activities (21), confirming this application. In fact, magnolia bark extract has been promoted as an anti-depressant and anti-anxiety agent without the side effects of tricyclic antidepressants (22).
APPENDIX 4. Modern Use of Salvia as a Sedative
Salvia, Dan Shen (the Chinese name implies a cinnabar-colored ginseng-like herb) has long been known as a sedative, but is not often used as such. It is an ingredient in the traditional Tian Wang Bu Xin Dan and the 20th Century brain-nourishing and sedative patent Bu Nao Wan. Modern research has demonstrated the sedative quality of an active component of salvia, miltirone, in animal models that predict clinical tranquilizing effects. Salvia has been incorporated into TCM treatments for insomnia, dementia, and other effects of brain dysfunction. Salvia is thought to have blood nourishing and blood vitalizing effects similar to that of Si Wu Tang , to have cooling effects like that of red peony (Chi Shao), and to have calming effects similar to that of ginseng.
A formula developed by the current author, called Salvia/Amber Tablets, illustrates its use in the context of treating shen disorders. The formula is:
Dan Shen Salvia 30%
Hu Po Succinum 18%
Suan Zao Ren Zizyphus 16%
Long Chi Dragon tooth 13%
Zhu Li Bamboo sap 13%
Ren Shen Ginseng 10%
The formula is intended to infuse courage to the heart to overcome fright. Ginseng and amber (succinum; spirit of the tiger) may confer the will or courage that has retreated under the pressure of traumatic external events. The key herb salvia calms the agitated spirit. Salvia and amber are both recognized as blood-vitalizers; when used with the qi tonic ginseng, they can restore the circulation that has been impaired by fear. To these herbs is added the dragon's tooth, which is a sedative for fright, and it represents the crystallization of the dragon in the earth (dragon and tiger, in Taoist literature, represent the yang and yin, respectively). There is also bamboo sap, the crystallization of the essence of bamboo that is found at the joints of the bamboo stem. Like dragon's tooth, it is used for calming fright, but it also dissipates the phlegm-mist that obstructs the orifices. Zizyphus nourishes the heart to aid the spirit in gaining rest. The entire formula enhances the basic heart functions; the formula clears heat, nourishes the yin essences, vitalizes blood circulation, and calms the spirit. In the bookMental Dysfunction as Treated by Traditional Chinese Medicine (23) there is a section on the syndrome of "deficiency of heart and lack of courage," with the following comments:
1. When the heart is in a deficient state, the soul [shen; spirit] is rolling and restless.
2. Lack of courage results in fright and timidity.
3. Therapeutic principle: benefit the qi and subdue the fright; calm the soul and steady the will.
The author, C.S. Cheung, mentions in this context "the pill to calm the soul and steady the will" (An Shen Ding Zhi Wan also called An Shen Yuan Zhi Wan; mentioned in the previous chapter), which has the chief ingredients ginseng and dragon teeth (others: hoelen, fu-shen, polygala, acorus). He recommends using this together with Zizyphus Combination (which has a large dose of zizyphus) for "serious cases."
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