Si Ni San, the Representative Herb for Qi Stagnation

Course: Syndrome-Based Herbs and Formulas Date: January 11, 2010 Class #: 2

Si Ni San, the representative herb for Qi stagnation. 4 major herbs: Chai hu, bai shao, zhi gan cao and zhi shi. Need to memorize this for the test on week 4 (and probably final). All proportions are equal.

Chai hu (6g)  Raises Qi (lifting the Yang Qi)  Releases the exterior (disperses)  Spreads Liver Qi  Soothes Liver  Clears Heat Bai shao (6g)  Softens Liver  Nourishes blood and yin

This controls the side effects of Chai hu and is astringent. Zhi gan cao (6g)  Tonifies middle Jiao  Harmonizes the taste

Gan cao is sweet and bai shao is sour which balances and harmonizes the Liver, relieves spasms, and stops pain. Zhi shi (6g)  Moves Qi

Zhi shi breaks up Qi stagnation and works on the gastrointestinal tract (SI and LI), lower abdomen predominantly. Spleen is highly involved in the SI function – SI absorbs the nutrients and separates out turbid from clear, which is integrated with the digestive Spleen function. Chai hu lifts the Qi and Zhi Shi descends the Qi. This promotes the circulation of Qi.

If you want to soothe the liver more or soothe the chest you can change the dosage to emphasize one area over another.

Si ni tang This formula also treats cold in 4 extremities. This is for Yang Qi that is almost gone. The difference between this and liver qi stagnation symptoms is that the whole body is cold rather than just the 4 limbs. If you want to identify this problem, check the trunk of the body for cold. 3 herbs in Si Ni Tang to build the Yang Qi. Gan Jiang The 4 limbs are related to the Sp/St. Use Gan jiang – dried ginger Fu Zi This is the base which is the Kidney Zhi Gan Cao Harmonizes You can add ginseng Know for later tests.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 1 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Types of Liver Qi Yu and the formulas that love them Liver Qi yu comes in several exciting flavors:  Lv qi yu without deficiency  Lv qi yu with blood xu  Lv overacting on Sp  LV overacting on St with and without heat

Liver Qi yu with no deficiency This is more about excess and the focus is on the Liver. You do not tonify. Pain is a key along the liver channel – hypo area, breasts, menstrual cramps, genital pain. There’s often more complaint in the flanks.

Chief formula: Chai Hu Su Gan San

Si Ni San is the base for this formula: chai hu, bai shao, zhi gan cao, and zhi… except it’s zhi ke rather than zhi shi. Zhi ke opens the chest area and the flanks. Xiang fu soothes the liver qi and the blood as well. Chuan xiong is for moving blood.

The focus is on the Liver Qi. This whole formula moves more Qi and blood – focuses on pain. Remember: if there is no deficiency, you don’t use Xiao Yao San! If there is no xu, there is excess and there will be pain, especially in the breast/chest area and the patient has a lot of stress. Xiao yao san is more harmonizing. Can’t use this formula for a long time, which is fine because you should correct the problem by giving this formula.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 2 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun You can use this even with blood deficiency signs. . . hmmm.

Do not need to memorize the dosage…it’s not on the test, but it’s a nice bonus.

Liver Qi Yu with Blood Xu or Liver Overacting on Spleen Unlike the previous formula and syndrome, this one does have deficiency signs. There might be pain with this syndrome also, but you will see deficiency. You could have a patient with pain during the periods or prior to. You could put them on Xiao Yao San for most of the month, then shift to Chai Hu Su Gan San the week prior.

What happens: Liver stagnation causes a Spleen xu and thus a blood xu. The blood can then not nourish the liver and contributes back to LV yu.

Liver Qi stagnation signs:  Depression, moodiness  Hypochondriac fullness and pain  Bitter taste in the mouth  Irregular menstruation, dysmenorrhea, PMS  Dry mouth and thraot when there is stagnant heat Blood xu signs:  Headache, dizziness  Floaters and blurred vision Spleen xu signs:  Fatigue  Poor appetite  Abdominal distention  Gas and bloating, esp after eating  Chronic diarrhea Pulse: wiry due to lv qi yu and thin due to blood xu. can be wiry and weak Tongue: pale with or without TM or normal

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 3 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Representative formula: Xiao Yao San (powder)

Look at that badass dosages above! This is a powder. It’s dispensed differently than raw herbs. Pay attention to the formulas and whether they are powdered or not.

You need to know the Liver physiology – always need to support the yin of the Liver: bai shao and zhi gan cao. Blood is supported by dang gui and bai shao. Chai hu is combined with bo he which helps the Liver Qi function – soothes and raises the Qi.

Spleen deficiency is addressed with bai zhu and fu ling. Zhi gan cao helps as well by tonifying spleen. Could also add ginseng which when combined with other herbs in this formula is Si Jun Zi Tang (spleen xu formula). Shao yao gan cao tang is a softener for the liver and a muscle relaxer.

Wei Jaing above is Sheng Jiang which warms the MJ. Wei means it is roasted which makes the warming function stronger.

Xiao yao san regulates the menses by soothing liver, regulating blood, and nourishing the Spleen which generates the blood. Liver stores it, Spleen generates it.

Know Xiao Yao San’s modifications – Jia Wei (zhi shi and mu dan pi), shu di huang to tonify. If there’s more liver stagnation, add xiang fu (don’t boost chai hu!).

Liver Overacting on Stomach without Heat Chief sx: stomach ache. Might also have poor appetite, might not. Appetite is more related to spleen than stomach. If temporary loss of appetite (like my wife pissed me off and I didn’t want to eat yesterday), this doesn’t count! We’re talking long term loss of appetite. May also have gas and bloating, but may not. There will likely be more nausea, vomiting and belching, which are more stomach related. Symptoms do become worse with stress, especially the stomach ache.

Remember: no heat signs!

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 4 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Pulse will be wiry, tongue can be normal.

Formula: Chai Hu Su Gan San

Liver Overacting on Stomach without Heat Chief sx: Stomach ache with acid reflux, worse with stress. They often have sour regurgitation, gas and bloating, but not always. Heat is indicated by voracious appetite and easily hungered. They may be irritable and easily angered. Look for a red tongue with a yellow coat and a wiry/rapid pulse.

Formula: Zhuo Jin Wan

Huang Lian – 9 g This formula ratio is 6:1 and is ground into a Wu Zhu Yu – 1.5g powder then pressed into pills at 6g per pill.

This is liver qi overacting on stomach with fire and heat. Symptoms are all “up” sx: acid reflux, regurgitation, belching. You need to reduce the fire organ to calm the son that is the stomach – thus you need to reduce heart which is what huang lian is for. Huang lian also clears the stomach heat, so this herb is a great choice here. That’s why huang lian is the chief herb here.

Why not use chai hu or xiang fu to calm the liver excess? Wu zhu yu is a warm herb which is why it’s a 6:1 ratio. We want the function of this herb, not the nature! Wu zhu yu controls rebelliousness and works on the Liver.

You don’t use this formula long term – first huang lian is way bitter, and 2nd it could damage the stomach because it’s so cold. In the clinic you could substitute huang qi which is a softer herb on the system. You could use zhi zi too.

You could further add herbs that treat acid reflux: Hai piao xiao, hai ge ke, duan wa leng zi, duan long gu, duan ju li. You can also combine with bei mu for phlegm. If pt has nausea/vomiting, you can add zhu ru.

Stagnation in the Digestive System (Food Stagnation)

There are 3 versions of this: food stagnation in the MJ, food stagnation in the ST and intestines (which is really a Qi stagnation – it’s not called food at this point), Qi stagnation in the intestines.

Food stagnation in the Middle Jiao Symptoms are:  Pain with aversion to touch  Belching which relieves the pain  Bad breath  Nausea and poor appetite (which is temporary because it’s just due to food stagnation)  Vomiting wich relieves the pain

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 5 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun  May have diarrhea which may have a foul odor and could be accompanied by gas.  Tongue will have a thick greasy coating – that bean curd coating we talked about in Diagnostics.  Pulse will be slippery or strong.

Food stagnation should be temporary – your stomach should self-correct. . . unless you have a Qi stagnation problem that causes this over and over. If you overeat meat or other undigestibles (which are mostly damp/mucous producing foods) the stomach won’t work as well and won’t digest well. If it sits there for a long term (24 hours for instance) you get the sour regurgitation because of heat which is generated by the stagnation and combines with the naturally hot environment of the stomach. The heat then generates upward movement – rebellion. If your body can’t resolve this it becomes a pathogen. You must then help the digestion and move or transport the food through.

Sidebar: Undigested food in stool is SP qi xu with KI yang xu. Digestive tract is like a pot which needs fire to cook the food. Mostly you will see morning diarrhea with undigested food in the stool. You need not only Qi, but Yang to thoroughly cook the food. Check Maciocia’s book on foundations for the graphic on this.

Representative formula: Bao He Wan

Shan zha Improves digestion, reduces food yu, These 3 are for food stagnation esp from meat and fats Shen qu Improves digestion, reduces food yu, esp from alcohol and fermented foods. Lai fu zi Improves digestion, reduces food yu, esp starches. Also resolves phl-damp and regulates the Qi Fu ling Strengthens the SP, dries damp and These 2 are part of er chen tang. stops diarrhea Ban xia Resolves phl-damp, harmonizes the ST, descends the rebellious Qi, and stops n/v Chen pi Moves qi, dries damp, harmonizes ST, This transports stops n/v Lian qiao Clears heat and reduces accumulations. Why this and not huang lian? Because lian qiao goes up. If you choose herbs that go down, this is the long way to process it out. The stomach is above th diaphragm – move the heat out closer to the source of the problem – move the heat out and up.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 6 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Food Stagnation in the ST and Qi stagnation in the Intestines Sx include:  Intestinal symptoms such as diarrhea (excess type) with strong foul odor or constipation! o Pain which is relieved after BM o Looks more like damp heat, but isn’t exactly.  May have a history of overeating  Can have stomach ache, belching, nausea, poor appetite due to food stagnation.  Tongue: thick, yellow, greasy coat  Pulse: excess pulse that is rapid and full or slippery.

Above the diaphragm, you help the digestion. Below the diaphragm you help the BM

Formula: Zhi Shi Dao Zhi Wan Target is the intestinal area.

Da huang This is the chief. Clears heat and purges Pushes the crud out. Induce bm to move Zhi shi Minister. Moves Qi and relieves the pathogens out. True either for stagnation diarrhea or constipation. Don’t focus on diarrhea as a sx, but the reason for it – food stagnation. Ze xie Deputy. Drains damp, stops diarrhea Helps release downward Fu ling Huang qin Deputy. Clears heat, dries damp, stops Huang lian diarrhea Shen qu Deputy. Relieves food stagnation and Helps digestion resolves damp Bai zhu Strengthens Sp and dries damp. Protects Qi.

This is used for a couple of days. That’s all you need to move out the food stagnation. Don’t use this with diarrhea minus stagnation! Look for that tongue coating!

Only for excess cases. Caution/Contraindication during preggers.

Qi Stagnation in the Intestines Chief area is the abdominal area.

SX include:  Qi yu with gas, bloat, ab distention and/or pain. Gas release relieves distention and pain  May have diarrhea

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 7 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun  May have a history of food allergies A few hours after eating (even regular eating and not overeating) the ab area is painful, goes to the bathroom multiple times  May have colitis, etc syndromes. This isn’t constipation with focal or other distention. This is due to Qi yu. What’s the difference: you can feel hardness with constipation and pinpoint the area. With qi yu the pain and distention will move around.

You need to move qi and get rid of damp.

Formula: Mu Xiang Shun Qi Wan The idea is move the Qi and descend it (because the problem is below the diaphragm), then dry damp and stop pain.

Mu xiang Move qi, harmonize MJ Xiang fu Soothe liver Bing lang Descends Qing pi Descends Move the qi Chen pi Zhi ke Cang zhu Dampness Hou po Decends Dampness + move qi Sha ren Dampness + move Qi + stop pain Zhi gan cao Harmonize digestive Sheng jiang

Not for long term use: 1-2 weeks tops. If you use for 1 week and doesn’t work, stop. It the patient takes it too long they will have gas bloating again, but due to SP xu generated by this formula – this exhausts the Qi. Also be careful that the patient doesn’t have a deficiency already which can be exaccerbated by this formula.

Stagnation in the Chest

Phlegm Heat and Qi yu in Chest or Upper Abdomen Usually there’s a combination of Qi yu in the chest with other stuff – like phlegm. Symptoms include:  Chest and gastric tightness/discomfort which increases with pressing/touching  Cough with expectoration of yellow phlegm Make sure this isn’t pneumonia! This also has chest pain, cough, phlegm. Usually accompanied by fever.  Tongue: thick, yellow coating  Pulse: wiry, slippery, rapid This formula also helps with pneumonia, but you need to add more herbs: qing ren for instance. Huang qin for lung heat. And more.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 8 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Xiao Xian Xiong Tang

Huang lian Minister. Clears heat, rel stagnation at ST area. Bitter and descends Ban xia Deputy. Descends qi, relieves stagnation and phlegm. Pungent taste that opens and disperses Gua lou shi Chief herb. Clears heat, resolves damp, (whole) opens the chest. Also benefits ST as well as LU meridian.

Obstruction of Yang Qi in the Chest (HT)

SX:  Cold sensation an stagnation in chest, fullness  Chest pain is usual, may radiate to back of chest and cause poor sleeping  Possibly dyspnea and SOB  Palpitation, other ht signs  Tongue: white, greasy (with phelgm sx)  Pulse: deep, thin

Formula: Gua Lou Xie Bai Ban Xia Tang

Gua Lou Opens the chst and moves qi Shi Xie bai Moves Qi Ban xia Resolves Phlegm Bai Jiu Bai jiu is white alcohol – like a grain alcohol, which is really warm and warms the Yang Qi.

This is the basic formula and can be modified. For more cold you can add dan shen for instance which targets the chest. You can add blood stasis herbs, etc.

You can use this formula to treat coronary disease, esp w/ hypo pain or intercostal neuralgia, etc. You can use this formula long term – 6 months.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 9 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Six Stagnations This is almost always tested. The six stagnations are Qi, blood, phlegm, damp, food, and fire stagnation.

Sx:  Fullness and distention in chest/diaphragm  Fullness and distention in the ST/ab  Belching, acid reflux, nausea, vomiting, poor digestion  Tongue: normal  Pulse: normal or wiry

Formula: Yue Ju Wan

Xiang fu Qi yu (depends) Phlegm yu Shen qu Food yu Chuan xiong Blood yu Cang zhu Damp yu Zhi zi Fire yu

Which is the chief depends upon what the main problem is. In the case above, the chief is Xiang fu which is causing all other sx.

Dosage: 6 – 9 g at a time. All herbs have the same dose.

Qi Yu with Phlegm in the Throat That’s plum pit qi. These folks have liver qi yu. It’s not just phlegm causing the problem. We’ll cover the formulas in another area, but the thing you use is ban xia hou po tang – ban xia, hou po, fu ling, sheng jiang, and zi su.

Qi yu in the four limbs and joints Generally, not necessary to treat this with herbs – just move, dude! That will move the Qi. Exercise, stretching will do the job. Why take herbs?

Test: Know the difference between bao he wan and zhi shi dao zhi wan. Case study on xiao xian xiong tang.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 10 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun Rebellious Qi

Rebellious Qi can affect primarily Lung and Stomach. Also Liver, but we call that Liver Yang rising.

Lung Qi rebellion = cough, asthma, SOB. Lungs are supposed to disperse and descend. There are formulas for the different pathogenic influences that are causing the qi to rebel – heat, cold, etc. Regardless, you must restore the lung’s normal function. Ma huang, qing ren, and gan cao are some basic herbs for this. ST qi rebellion = belching, n/v, hiccup Stomach is supposed to move the Qi downward. When it does not, stuff starts coming upward. Liver yang rising = hypertension, headaches.

Syndromes – Winter 2010 www.CatsTCMNotes.com Page 11 of 11 Disclaimer: This is not an official AOMA document, is intended for reference only and is not a replace for your own class notes. This document is available for your use As Is and may contain errors and omissions. Cat Calhoun retains full copyright ownership, rights and protection in all material contained herein. You may use this document for your own purposes and distribute it to other people provided you attribute it as having been generated by Cat Calhoun and disclose that it available free of charge on CatsTCMNotes.com. © 2010 Catherine (Cat) Calhoun