Using Heat Clearing Herbs to Calm the Spirit

Using Herbs That Clear Heat To Calm The Spirit

Cara O. Frank, L.OM. Dipl. OM.

Introduction:

Chinese medicine has always understood and treated the body and the spirit on a continuum. Throughout history, references to emotional experiences are often (but not always) described in terms of their physical symptoms.

The impact that heat-clearing herbs and formulas have on the spirit is often underestimated. The practical application of these herbs and formula families can improve our clinical precision and expand our repertoire of formulas that we call upon to soothe the spirit and ease suffering. Although these groups of medicinals are not typically thought of as “spirit calming”, as we shall see, there are numerous historical references of their clinical usage and application.

Inspiration

Recently, I have had the privilege of studying with Dr. Huang Huang. Huang is a Shang Han Lun Scholar from Nanjing. His special focus has been the development of the system of 10 body types. These body types represent a kind of herbal archetype. Just as we might diagnose a person as having a wood, or fire constitution, Huang presents a system of constitutional treatment rooted in the medicinals and formulas of the Shāng Hán Lùn Treatise on Cold Damage.

His system is centered on a deep understanding of the character of an herb and its associated formulas and the patterns that are treated by it. In this system, an herb can reflect a type of person or way of being in the world as well as a predisposition towards developing certain kinds of disease pattern. Huang presents with such clarity that he reduces the most complex cases to their fundamental components: the qi dynamics of the body. His perspective is refreshing in it’s depth, focus, and simplicity. It reminds us that Chinese herbs treat an entire gestalt: how a person comes into the world and how they are predisposed towards certain types of imbalances.

In Five Element theory, there is an idea of a Causative Factor (CF. The CF is a core gestalt that informs who and how we are in the world. It predisposes one towards a set of symptoms and behaviors based on the strengths and weaknesses of this element and the interplay of other related elements. Similarly, Huang’s system presents constitutional patterns that are reflected by the character of an herb, its associated formulas, and the diseases that are treated by it. Therefore, we might say that a person has a chái hú Radix Bupleuri constitution. Their behavior reflects a chái hú imbalance. This predisposes them to develop chái hú diseases. Moreover, they will be treated with chái hú formulas.

Why is this important?

When diagnosing and treating anxiety and depression, students and practitioners often rely on medicinals and formulas from two broad categories: the settle and calm the spirit group, as well as the regulate qi and harmonizing categories.

Formulas that regulate the qi are often used to treat depression, while those that nourish and calm the spirit are primarily based on tonics and thus are used to nourish the heart blood and heart yin, tonify the kidney yin and strengthen the spleen qi. These strategies are effective for treating patterns of deficiency, in which case, the spirit will be calmed when it is nourished. These treatment strategies are not wrong, per se, and when the patient presents with signs and symptoms of xū xié deficiency-type pathogen it is the correct treatment. This is, however, an incomplete perspective. Throughout the history of Chinese medicine, heat clearing herbs and formulas have been used to alleviate emotional distress.

If we limit our herbal vocabulary for treating the spirit we only to herbs and medicinals from the calm the spirit categories of herbs and formulas, we do ourselves and our patients a disservice. In fact, I would argue that it reflects a western reductionist perspective of treating only the spirit (and not the body-mind-spirit). If we limit ourselves to only this category of herbs and formulas, we are neglecting to honor the traditions of Chinese diagnosis and treatment. In fact, using heat clearing herbs and formulas can form a deeply constitutional treatment: one that respects Chinese medicine and one that treats the entire person and not merely a symptom of emotional distress.

A similar line of thinking influences how we often value the clinical importance of six fu bowels. The five-zang viscera are usually considered more precious than fu. This undervalues the importance of fu organs: The fu are conduits for yin-fluids thus, they have a critical role in the generation and distribution of yin, blood and jin-ye throughout the body. Without the fu, we would die of malnutrition. To link these two concepts: heat-clearing herbs, which are generally bitter, balance and promote the digestive qi. Many of the formulas discussed in this article traditionally have been used to treat digestive stagnation and heat.

Heat clearing medicinals can be as constitutional and as deeply spiritual as using a tonic herb such as rén shen Radix Ginseng. The key is to understand the full nature of the herb or formula family, the constitution of the person and the disease pattern that the herb/formula treats. When this is honored, the person will be deeply supported.

So what are we treating?

Often, the term vexation is described without emphasis, and it’s easy to overlook the full weight of what this can mean clinically. In recent years, I have re-emphasized the value of this in my clinical practice. I’ve put the diagnosis of vexation at the forefront of understanding the actions of heat clearing herbs and formulas and how to use them to in the clinic to alleviate anxiety.

Heat cleating medicinals and formulas are used to treat problems of physical heat. General signs and symptoms of these patterns can include fever, red eyes, a bitter taste in the mouth, bleeding disorders, a red tongue, and a rapid pulse. Heat that affects the physical body will also affect the spirit. The body experiences a lack of stillness and the emotions will lack quiescence. The most common emotional scenario that we encounter when the body is affected by exogenous or endogenous heat is fán zào vexation and agitation. This article attempts to discuss vexation and agitation and stagnation patterns that are caused by, and are the cause of heat.

Terminology:

The scope of this discussion will primarily focus on the terms fán 烦vexation or irritability. According to the Practical Dictionary of Chinese Medicine[1] fán or xīn fán心烦heart vexation, refers to a feeling of unrest or irritability that focuses on the heart or chest region. Vexation can be observed in patterns of excess or deficiency heat. In severe cases, it is associated with agitation, i.e. increased movement of the limbs. The former is a subjective symptom, while the latter is an objective sign. Although they are different, they are usually considered one term since, in most cases, they occur in tandem and share the same disease mechanisms. This pattern is called fán zào烦躁vexation and agitation. The patient can’t settle down. They feel nervous and tense. They are reactive. They experience an inability to concentrate and are forgetful. They have difficulty memorizing.

There are approximately 90 references to fán in the Shang Han Lun- Treatise on Cold Damage. Associated terms include (but are not limited to) fán jīng bù’ān vexation and susceptibility to fright, fán yuan烦冤vexation and low spirits, Fán zào yì nù vexation, agitation, and irascibility.

Anxiety vs. Fán Zào:

Anxiety is the syndrome that most closely matches the pattern of fán zào. Both are similar, but yet, not identical syndromes. Let’s compare the definitions in the chart below:

Anxiety[2]

Fán Zào.

SOMATIC: Headaches, dizziness or lightheadedness, nausea and/or vomiting, diarrhea, tingling, pale complexion, sweating, numbness, difficulty in breathing, and sensations of tightness in the chest, neck, shoulders, or hands.

BEHAVIORAL. Behavioral symptoms of anxiety include pacing, trembling, general restlessness, hyperventilation, pressured speech, hand wringing, or finger tapping.

COGNITIVE. Cognitive symptoms of anxiety include recurrent or obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts or ideas, and confusion, or inability to concentrate.

EMOTIONAL. Feeling states associated with anxiety include tension or nervousness, feeling “hyper” or “keyed up,” and feelings of unreality, panic, or terror.

SOMATIC: A subjective feeling of heat and disquietude in the chest (vexation)

BEHAVIORAL: An objective fidgetiness of the limbs (agitation). [3]

Clearly both syndromes overlap. Both Anxiety and fán zào include symptoms of restlessness. Both include symptoms that involve the upper body, which is suggestive of qi rising. Both syndromes describe a sensation of tightness or disquietude in the chest. Anxiety also includes feeling of hyperventilating. This may or may not be part of Fán Zào. A sensation the chest is described as fullness, or glomus, but not specifically rapid breathing. Further, Anxiety can include catastrophic thoughts, which is not included in the scope of fán zào. Another perspective, especially in the case of xīn fán heart vexation, is the sensation of disquietude in the chest. The use of the character for heart 心 may have been referring to the stomach[4]. Therefore, the term may be referring to nausea.

Pathogenic heat is both the cause and the result of emotional distress. In a state of health, qi moves freely through the body. Qi is yang in nature. When it becomes blocked by any number of physical and emotional pathogenic factors, the resultant stagnation will generate heat. If there is depression/stagnation, then over time that stagnation will generate heat. When heat affects the Shen, then the mind lacks stillness, reflectiveness, and quiescence. The person is uncomfortable in his or her body: Nothing feels at ease. Anxiety, insomnia, and restlessness can ensue.

Any discussion of heat that affects the spirit must also include a discussion of depression. In TCM, depression- 郁 is also referred to as stagnation. The term can refer to an inhibited physiological function, with inhibition of emotional expression as well as the expression of frustration or irascibility. The liver or the wood element is most frequently associated with depression. Variations of liver patterns include Gān Qì Yù Jié Binding Depression of Liver Qi, Gān Yù Huà HuǒLiver Depression Transforming Into Fire. These patterns refer to heat that develops because of long-term stagnation. Like an engine caught in traffic, when there is long-term qi stagnation, the body over heats. Just as when the traffic clears and the car is moving, the engine cools, when the qi stagnation is resolved, the heat clears naturally.

Other pathogenic factors that cause stagnation- depression includes the Liù Yù The Six Depressions, which are stagnation of qi, blood, damp, fire, phlegm and food.

If there are signs and symptoms of stagnation/ depression, the treatment strategy will focus on regulating qi and clearing heat. If there is vexation/ agitation, then the treatment strategy focuses on clearing heat.

So what do we know for sure about heat?

We know that heat tends to rise or ascend. We know that heat stirs the body and the emotions. We know that the tongue will be red. We know that if there is full or replete heat, the tongue will have a yellow coating and that if there is deficiency or deficiency heat, it will have little coating. We know that if the emotions are affected, they will be the opposite of still and cool: Heat causes qi to rise: heat can result in feelings of n. Conversely, n causes heat, which causes the qi to rise. There is no cause and effect. There is simply a zhèng: a pattern. Another example of what this conundrum: Anger is not the cause of qi rising: Anger is qi rising, Depression is not the cause of qi stagnation, it is stagnation. Trying to determine which came first is beside the point. It’s a chicken and egg circle. This boils down to a shift in clinical perspective: rather than focus on the long trail of signs and symptoms that make a “diagnosis”, just focus on the simplest energetic imbalance: restore the body’s righteous qi mechanisms. The point is to simply understand the pattern of imbalance as it is affecting them right now.

Thus, a person who needs heat-clearing herbs will manifest signs of heat, and to state the obvious, they will not be cold. If there are symptoms of cold, then it will present as a cold-heat disharmony, which can be corrected with any number of harmonizing formulas: Bàn Xià Xiè Xīn Tang Pinellia Heart-Draining Decoction, Huáng Lián Tāng Coptis Decoction, Sì Nì Săn Frigid Extremities Powder, and so on. By attuning to the entire mind-body symptom presentation, we ensure clinical success. That having been said, carefully discriminate whether the heat is excessive or if it deficiency heat. This is easily determined by examining the tongue. Excessive patterns will have a coated tongue. Deficiency patterns will have less or no coat.

When diagnosing and treating the patient, a long recapitulation of a patient’s history

is not always of consequence. The key from which the diagnosis pivots is the patients Bing: the disease itself. As practitioners, we must ask ourselves, what is happening for the patient this very moment? How the patient feels and how they act and react in their life, in the world becomes their pattern and that pattern is an existential experience. So determining whether the heat causes the anxiety or the anxiety is caused by heat is beside the point. We treat the pattern of heat to resolve vexation and agitation. We treat all of heat’s manifestations. We treat the character of heat in the body-mind-spirit. Once the heat is cleared, the patient feels settled and with new clarity, is able to reflect more deeply on changes they should implement.

Historical references:

Huang is not the first practitioner to use to this model of treatment. The Japanese Kampo tradition has a long history of constitutional treatment. Kampo is a system that is rooted in the formulas from the Shang Han Lun. Hong–yen Hsu published several texts on this topic in the late 1970’s and early 1980’s. Although his books are difficult to read because the translations are dated and use Wade-Giles terminology, they are rich with detailed illustrations of the physical confirmation: body type, symptomology and, relevant to this discussion, emotional terrain.

References to the spirit calming effects of medicinals stretch back as far as the Shén Nóng Bĕn Căo Jīng Shen Nong’s Classic of the Materia Medica. This text has scant references to vexation, however there are numerous references to fright, fright evil and fright palpitations.

As previously mentioned, the term vexation is cited around 90 times in the Shang Han Lun. The Wiseman dictionary lists 13 variations of n。The Jīn Guì Yào Lüè Essentials from the Golden Cabinet is unfortunately not indexed well enough to count the entries, however certain chapters are germane to this topic. These include Chapter 3, The Pulses Patterns and Treatment of Bai He, Hu Huo and Yin Yang Toxin Disease: Chapter 8, Running Piglet Qi Disease andChapter 16, which discusses Fright Palpitations.

Bǎi hé bìnɡ Lily Disease can develop as part of the normal progression of of a febrile disease scorching the yin[5]. It is also the result of emotional frustration that results in internal fire that scorches the lung and heat yin. The patient looks normal, yet acts as if possessed by spirits. Symptoms include the desire to, but the inability to lie down, eat, rest, and walk. Aversions to smells, bitter taste in the mouth, reddish urine. The patient should be treated with bǎi hé Bulbus Lilii formulas such as Băi Hé Gù Jīn Tāng Lily Bulb Metal-Securing Decoction.

Later in history, the Wēn Rè Lùn Treatise on Warm-Heat Diseases is devoted to the discussion of heat patterns. In this text, pattern of insomnia from disturbance of the heart spirit due to lurking summerheat, suggesting the role of latent heat as a driving pathogenic factor.

Li Dong Yuan discusses vexation in the Pí Wèi Lùn Treatise on the Spleen and Stomach. His perspective is related to his theory of yin-fire. When the spleen and stomach are weakened and lose their normal upbearing and downbearing movement, the resultant stagnation causes heat from the heart and small intestine to overwhelm the spleen and stomach, causing a large, floating, wiry pulse, vexation and agitation, a bitter taste in the mouth with a dry tongue and throat[6].

In his text, Dān Xī Xīn Fă Teachings of [Zhu] Dan-xi,Zhu Dan-xi devotes a chapter to the treatment of “Heart disease”[7]: In chapter 79 he describes a pattern with racing of the heart, vexation and restlessness, impaired memory, clouded spirit. The treatment for this pattern is Zhū Shā Ān Shén Wán Cinnabar Spirit-Calming Pill. He also details that the pattern of mania withdrawal is mainly due to phlegm and heat.

In “ Ten Lectures on the Use of Medicinals from the Personal Experience of Jiao Shu De[8]”, there are fifteen entries for medicinals that treat vexation. Nine that treat vexation- agitation and six entries that treats vexing heat in the five hearts. The heat clearing ones that he references includes chái hú Radix Bupleuri, huáng lián Rhizoma Coptidis, zhī mŭ Rhizoma Anemarrhena, dàn zhú yè Herba Lophatheri, zhú rú Caulis Bambusae in Taenia, lián qiào Fructus Forsythiae, zhī zĭ Fructus Gardeniae, lóng gŭ Os Draconis; Fossilia Ossis Mastodi and mŭ lì Concha Ostreae.

Medicinals and Formulas:

The medicinals discussed in the article are limited to those that appear in the Shang Han Lun and The Wen Bing Lun. This doesn’t mean to suggest that these are the only ones that can alleviate vexation, but rather, narrows the scope of the discussion to those that are the most widely discussed in historical literature.

This article will discuss the flowing medicinals:

    ·Huáng lián Rhizoma Coptidis

    ·Shí Gāo Gypsum Fibrosum

    ·Gé Gēn Puerariae Radix

    ·Zhī zĭ Fructus Gardeniae

    ·Lián qiào Fructus Forsythiae

HUÁNG LIÁN Rhizoma Coptidis

Huáng lián is bitter and cold. It enters the Heart and Stomach channels. It drains stomach fire, clears heat, and dries dampness. It stops bleeding, treats boils, infections, and sore throat. Very importantly, it treats glomus below the heart that causes heat and pain.[9] Huáng lián has a profoundly calming effect on spirit. Because it drains excessive heart fire, huáng lián treat irritability, delirium, and disorientation. Agitation, anxiety, obsessive compulsive disorder, attention deficit, headache, insomnia or profuse dreaming all fall under the umbrella of emotions addressed by huáng lián. In early literature, the key symptom that huáng lián treats is vexation in the heart. Thus, one can make an argument that the herb is primarily one to treat the spirit. In the huáng lián presentation the person cannot settle down: they are worried and anxious, nervous, and are easily wakened. The entire constellation of these signs and symptoms form a pattern that can be called Huáng lián disease. The trifecta of symptoms that for using Huáng lián includes:

    1.Fán Zào vexation, agitation.

    2.Focal distention: glomus.

    3.Diarrhea.

Additionally, bleeding disorders from heat can be included in this group.

Huáng lián has a specific tongue and pulse presentation: The pulse is for the most part slippery and rapid. The tongue is red with a firm, or tough appearance. There may be red prickles and a thick yellow, dry coating. If the tongue is not coated, or the body pale, then huáng lián should be used cautiously or not at all. In comparison, in a Shí Gāo presentation the face will be red. The Huáng lián complexion may be pale, but the lips, tongue, and throat are red.

Two key huáng lián formulas treat patterns of heat above and cold below. Bàn Xià Xiè Xīn Tang Pinellia Heart-Draining Decoction being the most important example.

Bàn Xià Xiè Xīn Tang Pinellia Heart-Draining Decoction

Huáng lián

黄连

Rhizoma Coptidis

3g

Huáng qín

黄芩

Radix Scutellariae

6g

Rén shēn

人参

Radix et Rhizoma Ginseng

6g

Bàn xià

半夏

Rhizoma Pinelliae

9g

Gān jiāng

干姜

Rhizoma Zingiberis

6g

Zhì gān căo

炙甘草

Radix et Rhizoma Glycyrrhizae Praeparata cum Melle

2g

Dà zăo

大枣

Fructus Jujubae

4pc

A related formula is is Huáng Lián Tāng Coptis Decoction.

Huáng lián

黄连

Rhizoma Coptidis

6g

Gān jiāng

干姜

Rhizoma Zingiberis

6g

Guì zhī

桂枝

Ramulus Cinnamomi

6g

Bàn xià

半夏

Rhizoma Pinelliae

9g

Rén shēn

人参

Radix et Rhizoma Ginseng

3g

Zhì gān căo

炙甘草

Radix et Rhizoma Glycyrrhizae Praeparata cum Melle

6g

Dà zăo

大枣

Fructus Jujubae

4pc

Both of these similar formulas use a sophisticated combination of warm and cold ingredients, both formulas correct an ascending and descending qi mechanism, thereby yin and yang to be harmonized. By clearing heat from the heart, huáng lián allows the spirit to become calm, settled and focused. For this reason, Huang used Huáng lián can be used to improve memory.

One if the best examples of the use of huáng lián’s ability to calm the mind is the formula Huáng Lián Ē Jiāo Tāng Coptis and Ass Hide Glue Decoction

Huáng lián

黄连

Rhizoma Coptidis

12g

Huáng qín

黄芩

Radix Scutellariae

6g

Bái sháo

白芍

Radix Paeoniae Alba

6g

ē jiāo

阿胶

Colla Corii Asini

9g

Jī zǐ huáng

鸡子黄

Galli Vitellus

2 yolks

For practical and esthetic purposes, we don’t add egg yolks to the decoction. Advise your patient to eat soft cooked eggs while taking the decoction.

The formula treats xū fán deficiency vexation. This is diagnosed by palpating the epigastrium, under the sternum. The patient will feel discomfort, but the practitioner will not feel resistance. In contrast, when the epigastrium of the Bàn Xià Xiè Xīn Tang patient is palpated, it will feel painful to the patient and the practitioner will feel stiffness or resistance as well. Symptoms include irritability and anxiety with a sensation of fullness in the chest that prevents the patient from lying down. The complexion of this patient is often pale (reflecting blood deficiency) with red lips (reflecting heat).

This formula employs a sophisticated pairing of of huáng lián and ē jiāo. Huáng lián drains heart fire to eliminate vexation, but it is drying. ē jiāo enriches kidney water, yet it is cloying. When water is nourished, then it can ascend to the heart. When fire is directed downwards, then the kidneys are warmed. Thus, the formula treats the pattern Heart and Kidneys lacking communication. Further, both medicinals stop bleeding. Because huáng lián clears stomach fire, the formula might be used to treat gastric ulcers. Huáng lián is used to clear heat and dry dampness, thus this formula can also be used for coughing blood.

The final formula we will discuss that uses huáng lián to calm the spirit is Huáng Lián Wēn Dǎn Tāng Coptis Gallbladder-Warming Decoction

Huáng lián

黄连

Rhizoma Coptidis

6g

Bàn xià

半夏

Rhizoma Pinelliae

6g

Fú líng

茯苓

Poria

6g

Chén pí

陈皮

Pericarpium Citri Reticulatae

9g

Zhú rú

竹茹

Caulis Bambusae in Taenia

6g

Zhĭ shí

枳实

Fructus Aurantii Immaturus

6g

Gān căo

炙甘草

Radix et Rhizoma Glycyrrhizae

3g

Dà zăo

大枣

Fructus Jujubae

3 pcs

Shēng jiāng

生姜

Rhizoma Zingiberis Recens

5 slices

The actions of the formula are to clear phlegm-heat, harmonize the stomach, quell nausea and vomiting, clear the gallbladder and regulate the qi. The indications include dizziness, nausea, dream disturbed sleep, glomus, restlessness, being easily startled, irritability and bitter taste in the mouth. The tongue is red with a thick yellow coat and the pulse is slippery or wiry.

Bàn xià is discussed in textbooks as being used to treat phlegm and alleviate nausea. However, the realm of its use is wider. It includes the experience of anxiety. This is easily evidenced by the actions and indications of Wēn Dǎn Tāng. When combined with huáng lián, it is especially effective for treating anxiety and irritability.

When I studied in the at the Xi Yuan Hospital in Beijing, Wēn Dǎn Tāng was the most commonly used formula in the psychiatry-neurology department. A person with a Wēn Dǎn Tāng presentation is often simply diagnosed as being “neurotic”. This is not the pejorative declaration that it seems to be. It is merely a statement that the disease has affected their nervous system. The formula’s actions hinge on the application of bitter, descending herbs that clear heat from the Gall Bladder. On the surface, it seems that there are no spirit calming herbs in the formula. However, the formula deals with the core pathology of phlegm heat as it impacts the spirit. Huang regards Bàn xià similarly to the way we might think about the homeopathic remedy Pulsatilla. The constellation of signs and symptoms for both include: anxiety, phlegm, and a kind of clinginess. The bàn xià person is wide-eyed, anxious, and easily startled. They are fearful and nervous. Bàn xià presentations are often encountered with Posttraumatic Stress Disorder. According to Huang, when using Bàn xià for psycho-spiritual disorders, we use large doses; up to 30 grams daily. He uses smaller, more typically standard doses to harmonize the stomach and quell nausea.

SHÍ GĀO Gypsum Fibrosum

Shí Gāois the main medicinal for treating Yang Ming stage disorders. Symptoms include what is often referred to as the “The Big 4”: great fever, great sweat, great thirst, and great pulse. The person feels hot subjectively and prefers cold food and drinks. It’s the feeling one might experience in a heat wave in the summer.

Encountering a shí gāoperson is to meet a loud, boisterous, short tempered, red-faced person. Because the medicinal enters the yangming channels, there can be symptoms of stomach fire, such as reflux, bleeding gums and inflammation. Other symptoms that shí gāotreats include fever, toothache, headache, and swollen and painful throat. Furthermore, the patient experiences vexation and agitation. Because this is a syndrome of great heat, symptoms also include delirious speech, mania, psychosis, and schizophrenia. Milder shí gāopresentations might be encountered in those with with ADHD. Dr. Hsu writes that shí gāoand its representative formula; Bái Hŭ Tāng White Tiger Decoction can be used for delusions[10].

There are three key symptoms to a shí gāopresentation:

    1.The complexion of the patient will be red or ruddy and they may look haggard.

    2.Because heat has injured the fluids The tongue is dry with a thin coating. The pulse will be floating and large or flooding.

    3.The patients’ will look robust and tends to be sweaty. Their voice may be loud.

Shí Gāois included in several formulas that treat wheezing due to lung heat, most notably, Má Xìng Shí Gān Tāng Ephedra, Apricot Kernel, Gypsum and Licorice Decoction and Dà Qīng Lóng Tāng Major Green Dragon Decoction. I mention this because upon re-reading the Shén Nóng Bĕn Căo Jīng, Shen-nong writes that it mainly treats counterflow qi below the heart, fright and panting, dry mouth and tongue, hardness and pain in the abdomen. He then says that it eliminates evil ghosts. This paints a vivid picture of both asthma as well as the shortness of breath experienced with extreme anxiety.

An excellent formula example of the use of shí gāoto treat the spirit can be found by studying Zhú Yè Shí Gāo Tāng Lophatherum and Gypsum Decoction

Dàn zhú yè

淡竹叶

Herba Lophatheri

15g

Shí gāo

石膏

Gypsum Fibrosum

30g

Bàn xià

半夏

Rhizoma Pinelliae

10g

Mài mén dōng

麦门冬

Radix Ophiopogonis

20g

Rén shēn

人参

Radix et Rhizoma Ginseng

6g

Gān căo

甘草

Radix et Rhizoma Glycyrrhizae

6g

Gēng mǐ

粳米

Semen Oryzae sativae

20g

Indications for the formula include insomnia,nervous exhaustion, oppression of the chest, parched lips, restlessness, stifling sensation, a red tongue with a thin coating and a rapid-empty pulse

The formula treats the sequelae of fever with insomnia and irritability, mouth ulcers and chest oppression. The tongue is dry. The patient looks thin, dry, and anxious. They may be suffering from a chronic physical condition. There is a vestige of heat that disturbs the spirit. This can also be used to treat the side effects of chemotherapy.

Formula Analysis:

Sweet, bland and cool dàn zhú yè cools heat in the heart and shí gāo’s sweet and acrid properties disperse heat. Bàn xià is used to clear heat from the gallbladder, relieve anxiety, and harmonize the stomach. Mài mén dōng generates fluids, nourishes the yin, and calms the spirit. Rén shen and gān căo tonify the qi and generate fluids. Gēng mǐprotects the stomach.

The formula uses a lower dose of Shí Gāo than one would use when treating a yangming fever, suggesting that this presentation does not treat full heat. The primary goal of the formula is first to clear heat and, secondarily to nourish fluids and tonify the qi. In fact, the chief herb in the formula is dàn zhú yè. Dàn zhú yè enters the heart channel to clear vexation. Dàn zhú yè and Shí Gāo are both sweet medicinals. Historically, it was indicated for lingering vestiges of heat that cause insomnia[11]. Within the formula discussion, The heat is caused by fever. However, lingering emotions can generate heat as well. Fear, resentment, upset all can cause low level heat that disturbs the spirit in relation to sleep. The formula goes on to include bàn xià, which is down bearing and relieves anxiety. Bàn xià, mài mén dōng, and Shí Gāo all enter the lung and stomach channels. However, the acrid nature of Shí Gāo serves to vent the heat and re-order the qi dynamic. Yi Tian Shi, in Discussion of Warm Heat Pathogen Disorders makes this comment[12]: The formula is for when “One fears that although the stove no longer smokes, there is still fire within the ashes”.

The heat that Shí Gāo treats is in no way related to the heat of yin deficiency. It is yangming channel heat. To further expand on the Shí Gāo tongue: Even though there is great heat, the tongue does not have a coating because there is not substantial physical accumulation. If the tongue is coated, if the abdomen is firm upon palpation, then the conversation moves towards a dà huang Radix et Rhizoma Rhei presentation, as this is considered yangming with form.

    Contraindications:

Shí Gāo formulas are inappropriate[13] if:

    ·The pulse is thready, wiry, or deep.

    ·If there is no thirst

    ·If the patient is not sweaty.

GÉ GĒN Puerariae Radix

Gé Gēn- Rx Pueraria is sweet, acrid, and cool. It enters the Spleen and Stomach channels. Its chief actions are to raise the clear yang qi of the stomach, release the muscles and generate fluids to alleviate thirst. Further, gé gēn lowers blood pressure and treat headaches and dizziness.

Gé gēn huā- the flowers of gé gēn are used as an antidote to alcohol poisoning. Dr. Huang says that the key to understanding a gé gēn constitution lies in its ability to treat drunkenness. If we extrapolate on the feeling of drunkenness, we can expand that to include dizziness, confusion, and clouded thinking. Therefore, gé gēn can be used for when people experiences a lack of groundedness or clarity. Gé gēn allows clear yang to reach the head. Gé gēn is one of the best medicinals we have for clearing the mind. Think about gé gēn for its opening, mobilizing and softening action.

The gé gēn body type is that of a robust, muscular person who enjoys to alcohol. Since gé gēn releases the muscle layer, the medicinal treats muscular tension, especially in the neck and shoulders. There may also be thirst diarrhea and acne.

An excellent example of a gé gēn formula that can treat the spirit can be found in the formula Gé Gēn Qín Lián Tāng Pueraria-Scutellaria-Coptis Decoction

Gé gēn

葛根

Radix Puerariae Lobatae

24g

Huáng lián

黄连

Rhizoma Coptidis

9g

Huáng qín

黄芩

Radix Scutellariae

9g

Zhì gān căo

炙甘草

Radix et Rhizoma Glycyrrhizae Praeparata cum Melle

6g

The actions of the formula are to release the exterior and to clear yang ming interior heat, which results in a feverish sensation, foul-smelling or explosive diarrhea, a burning sensation of the anus after defecation, irritably with a feverish sensation in the chest and epigastrium, thirst, a yellow tongue coating, and a rapid pulse. It is often used to treat acute gastroenteritis and ulcerative colitis with a presentation of heat.

One of my favorite herbal exercises is to deconstruct and reconstruct the actions of formulas. It deepens my relationship with formulas by allowing me to see them with fresh eyes. Gé Gēn Qín Lián Tāng is such a formula. If we re-examine it through the filter of this discussion, we see now that in addition to its traditional applications listed above, the formula is also an effective strategy for treating vexation and agitation, headache, muscle spasms, dizziness and anxiety with heat.

Gé gēn releases the muscles, especially of the upper back and neck, so we might choose this formula when backache is part of the symptom picture. Both Huáng lián and gé gēn can lower blood pressure[14] Gé gēn improves cerebral circulation. Thus, the formula might be used to address behavioral changes caused by hardening of the arteries and related cerebral-vascular disorders. In this case, there would be other signs of heat, such as a dry red tongue and thirst. For this situation, we can modify the formula with medicinals to invigorate the blood, such as chì sháo Radix Paeoniae Rubra, mŭ dān pí Cortex Moutan and táo rén Semen Persicae.

ZHĪ ZĬ Fructus Gardeniae

Zhī zĭ is bitter and cold. It enters the Heart, Lungs, Stomach, Liver and Triple Burner. It clears heat from all three burners, draining it through urination. Additionally, it clears damp-heat jaundice and is used to treat damp-heat Lin syndrome. It cools the blood and relieves toxicity, thus is used when there heat causing blood to move recklessly.

Zhī zĭ treats vexing heat that and stifling oppression in the chest. Zhong Zhang Jing says that Zhī zĭ “resolves anguish and vexation in the heart and depressed heat bind”[15]. When Zhong Zhang Jing uses the term anguish, he means a feeling of harassment to the point where they cannot calm down, along with shallow and rapid breathing.

In addition to obvious signs of heat, such as red eyes, being easily angered and a bitter taste in the mouth, there are also a few key physical signs and symptoms of a Zhī zĭ presentation. When palpating the abdomen there is often pain and discomfort under the sternum. Look for tightness, rigidity, and a lack of yielding below the heart as well as fullness in the chest and hypochondirium. A hallmark sign of a Zhī zĭ pattern is to quickly palpate just below the sternum. If the response is painful and the patient is startled, then this strongly suggests Zhī zĭ pattern presentation.

Zhī Zĭ Dòu ChĭTāng Gardenia-Prepared Soybean Decoction

Zhī zĭ

栀子

Fructus Gardeniae

9g

Dàn dòu chĭ

淡豆豉

Semen Sojae Praeparatum

9g

This formula clears heat from constraint in the chest and diaphragm. It is used to treat lingering heat following a febrile illness. The heat causes insomnia with tossing and turning and, anguish in the heart[16]. This pattern is referred to as Xū FánDeficiency Vexation. Here, the term deficiency does not refer to depletion or insufficiency, but rather, that the epigastrium does not feel rigid or obstructed to the practitioner, however the patient feels discomfort when being palpated. Huáng Lián Ē Jiāo Tāng also treats this pattern, however the appearance of the person, and the accompanying signs and symptoms will differ. Huáng Lián Ē Jiāo Tāng nourishes the blood and yin and clears heat, so the complexion is pale or white with red lips. There may heavy menstrual or intestinal bleeding. The tongue will be red with a dry yellow coating and the pulse will be thready and rapid. In the case of zhī zĭ dòu chĭtang, the heat is in the lingering in the Qi level. The patient may or may not have a low-grade fever. This patient can’t settle down, and even sleep is filled with tossing and turning. In addition, in comparison to the tongue and pulse, here, the tongue is red, but with a pale yellow coating. The pulse in this case is floating, forceful and rapid.

Zhī Zĭ dòu chĭTāngis important for treating restless sleep patterns following emotional upset. Huang teaches that this formula is used when the patient is troubled, but unable to explain what is wrong. Using this formula helps them to express themselves clearly. In this case, clearing heat creates space to reflect within to gain insight into ones feelings.

Another familiar formula that uses Zhī zĭ to calm the spirit is Jiā Wèi Xiāo Yáo Săn Modified Free Wanderer Powder

Chái hú

柴胡

Radix Bupleuri

9g

Dāng guī

当归

Radix Angelicae Sinensis

9g

Bái sháo

白芍

Radix Paeoniae Alba

9g

Bái zhú

白术

Rhizoma Atractylodis Macrocephalae

9g

Fú líng

茯苓

Poria

9g

Zhì gān căo

炙甘草

Radix et Rhizoma Glycyrrhizae Praeparata cum Melle

3g

Bò he

薄荷

Herba Menthae

6g

Shēng jiāng

生姜

Rhizoma Zingiberis Recens

3-5 slices

Mŭ dān pí

牡丹皮

Cortex Moutan

6g

Zhī zĭ

栀子

Fructus Gardeniae

6g

This modification of the iconic formula Xiāo Yáo Săn Free Wanderer Powder is used to regulate the liver qi, nourish the blood and harmonize the liver and spleen, adds zhi zĭ and mŭ dān pí to clear heat that causes restlessness and irritability. Other symptoms can include sweating, a feeling of heat rising causing red ears, red eyes, breast distention, and menstrual irregularities: what we generally refer to as pre-menstrual syndrome. The pulse is wiry and the tongue is reddish.

Zhī zĭ releases heat from constraint that is commonly associated with the liver. In a circular relationship, qi stagnation-depression over time will generate heat, causing frustration and irritability. Over time, frustration and irritability results in qi stagnation-depression.

LIÁN QIÀO Fructus Forsythiae

Not all medicinals that clear heat affect the spirit per se: one key is whether the medicinal enters the heart channel. If so, then that can be a clue that it is used to treat fán zào: vexation and agitation. An excellent example of a medicinal that we rarely think about for calming the spirit is lián qiào Fructus Forsythiae. The Materia Medica 3rd edition writes this about it: lián qiào “Clears Heat and resolves toxicity. Reduces Abscesses and dissipates clumps.” Easily overlooked in the list of its actions is that it clears heat that has entered the pericardium causing loss of consciousness. Based on this commentary, one might never grasp the full impact this herb can have on the spirit.

Jiao Shu-de is more on track when he writes about lián qiào. As its primary action, he states that it clears heart fire. Its secondary action is to treat fire in the heart channel that spreads to the Small Intestine. Finally, it treats Heart Fire flaming upwards. Still, Jiao is for the most part, addressing consciousness that is affected by fevers and infections. Huang says that lián qiào is used to clear the emotions and get rid of agitation. He uses it to treats insomnia and irritability[17]. He likes to combine it with zhī zĭ for this purpose.

Huang created the formula the formula Ba Wei Chu Fan Tang- Eight Flavor Eliminate Vexation Decoction, which uses lián qiào to great effect.

Hòu pò

厚朴

Cortex Magnoliae Officinalis

10g

Bàn xià

半夏

Rhizoma Pinelliae

10g

Fú líng

茯苓

Poria

10g

Zĭ sū gĕng

紫苏梗

Caulis Perillae

10g

Lián qiào

连翘

Fructus Forsythiae

15g

Huáng qín

黄芩

Radix Scutellariae

10g

Zhī zĭ

栀子

Fructus Gardeniae

10g

Zhĭ qiào

枳壳

Fructus Aurantii

10g

The formula is a modification of Bàn Xià Hòu Pò Tāng Pinellia and Officinal Magnolia Bark Decoction, the iconic formula that treats Plum Pit Qi. Plum Pit Qi is described as the sensation of having a piece of roasted meat in the throat, however there is nothing there. In fact, it is wholly a pattern of constrained emotions. It is the physical sensation of the emotions caught in the throat. Zhī zĭ, lián qiào, and Huáng qín clear heat from the Heart to calm the mind. Hòu pò, zhĭ qiào and zĭ sū gĕng reduce bloating and distention and regulate the qi to relieve depression. Bàn xià and Fú líng resolve phlegm. Bàn xià is specific for relieving anxiety. One appealing part of the formula’s construction is that it relaxes the nervous system without being overly sedating. At first glance, one would not thing that the it was constructed to deal with anxiety. In a way, it doesn’t. Formula is effective, because it rectifies key qi mechanisms. In this way, the patient feels clear and calm, but not dulled.

By now, it is obvious that all of these medicinals and formulas overlap with one another. Chinese herbal medicine is a poly-pharmacy system based on time-tested couplings of medicinals.

Contraindications:

Not everyone with anxiety has heat. Therefore, of if tongue, pulse, and presentation do not show signs of heat, then other medicinals and formulas should be selected. If the tongue is a normal color, and the shape is swollen, with a white coat, then the patient should probably be treated with a bàn xià Rhizoma Pinelliae formula, such as Wēn Dăn Tāng Gallbladder-Warming Decoction. If the patient is more depressed and irritable, more than anxious, with tightness under the rib cage, then consider using one of the many of the Chái hú Radix Bupleuri formulas including Xiăo Chái Hú Tāng Minor Bupleurum Decoction or Sì Nì Săn Frigid Extremities Powder. If the patient is sweating and irritable with insomnia, with a tender pale red tongue, then select medicinals and formulas that are nourishing and restraining, such as Suān Zăo Rén Tāng Sour Jujube Decoction or Gān Mài Dà Zăo Tāng Licorice, Wheat and Jujube Decoction. If there is fatigue, loose stool, poor appetite, bleeding a pale tongue and a weak pulse, then is a pattern of spleen qi and heart blood deficiency that is best treated with Guī Pí Tāng Spleen-Restoring Decoction. And if the pattern shows clear signs of yin deficiency: with night sweats, vexing heat in the five centers (chest, palms and soles), palpitations, poor memory a reddish tongue with little coat and floating and empty pulse, then this is a pattern of heart yin deficiency that is best treated with Tiān Wáng Bŭ Xīn Dān Celestial Emperor Heart-Supplementing Elixir.

********************************

In my clinical practice, using herbs that clear heat to calm the spirit and settle the mind has significantly improved my clinical results. Whether the chief complaint is anxiety, depression, inability to concentrate or insomnia. With conscientious treatment, I often achieve immediate results. Patients feel centered, cooled, and present. When the heat that causes the spirit to be unsettled is cleared, the mind is able to be calm and focused. This cultivates a clear, still and reflective space within themselves allowing a person to grow and flourish.


[1] Page 273, A Practical Dictionary of Chinese Medicine, Nigel Wiseman and Feng Ye, 1998, Paradigm Publications

[2] thefreedictionary.com describes these symptoms for Anxiety

[3] A Practical Dictionary of Chinese Medicine, Nigel Wiseman and Feng Ye, 1998, Paradigm Publications.

[4] Jason Blalack discussed this in his blog post http://www.chinesemedicinedoc.com/misc-chinese-medicine-articles/irritability-vexation-fan-shang-han-lun/

[5] Pg. 69, Understanding the Jin Gui Yao Lue, Yuk-ming, Lardner, Peoples Medical Publishing House, 2008

[6] Pg. 62, Li Dong-yuan’s Treatise on the Spleen and Stomach, a Translation of the Pi Wei Lun, Shou-zhong, Jian-yong, Blue Poppy Press 1993

[7] Pg. 264, The Heart &Essence of Dan-xi’s Methods of Treatment, A Translation of Zhu Dan-xi’s Dān Xī Xīn Fă, Shou-zhong, Blue Poppy Press, 1993

[8] Mitchell, Shu-de, Paradigm Pubs,2003

[9] Glomus: refers to the sensation of a ball or lump below the diaphragm.

[10] Commonly Used Chinese Herb Formulas with Illustrations, Hong-Yen Hsu, Oriental Healing Arts Press, 1980, pg. 185

[11] Chinese Herbal Materia Medica, 3rd Edition, Bensky, Clavey, Stoger, Eastland Press, 2004, pg. 91

[12] Chinese Herbal Medicine, Formulas and Strategies, 2nd Edition, Sheid, Ellis, Bensky, Barolet, Eastland Press, 2009

[13] Wen Bing Tiao Ben- Systematized Identification of Warm Diseases.

[14] Zhong Hua Nei Ke Za Zhi (Chinese Journal of Internal Medicine),

1960:2:117

[15] Line 261, Shang Han Lun, Mitchell, Ye, Wiseman, Paradigm Publications,

[16] Line 76b.

[17] [17] Person… Illness… Prescription. An interview with Dr. Huang Huang by Michael Max. The Lantern. Volume 4-2

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Cara started helping me over 16 years ago. I had been trying to get pregnant for 7 years. She gave me ‘real’ herbs to boil and make tea. After getting pregnant, Cara helped my son Sam with food allergies. I now also have a daughter (age 13) and another son (age 9). I was recently approached at a party after I said that herbs and acupuncture cured my infertility. Thanks, and thank you Cara, for your help. Being a mom…it’s the best part of my life.

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