Disorders of the spleen and stomach

By Prof. Dian Bang-Shi. Translated and edited by Attilio D'Alberto

Ancient Chinese medical textbooks that discuss Spleen and Stomach disorders include the typical symptom manifestations of abdominal distention, abdominal pain, nausea, acid regurgitation, gastric discomfort and irregular bowel movements. Today, Chinese medicine's categorisation includes modern allopathic medical diseases such as chronic gastritis, peptic ulcer and several liver and gallbladder disorders. With any Spleen and Stomach disorder, the pattern differentiation and treatment strategy should be based upon the variations of yin and yang, qi and blood, excessive and deficiency as well as hot and cold patterns and zangfu theory. In this article, Prof. Shi outlines each pattern differentiation associated with the Spleen and Stomach. For each categorisation, a pattern analysis, treatment strategy, herbal formulae and individual herbal combinations are provided. This information is based upon a wide and deep knowledge of the classics, quotes from which are presented, along with his vast clinical experience. In certain instances, his classical and clinical knowledge is utilised to provide insights into treating the complex nature of Spleen and Stomach disorders.

Transformation and transportation

The physician Wang Jie Zhai during the Ming dynasty stated that 'the Stomach receives and digests food whilst the Spleen governs transportation and transformation, transforming the food into jing qi'. Many physicians during the Qing dynasty stated that 'the function of 'receiving and digesting' and 'transformation' is different and according to this it is necessary to differentiate between the Stomach and Spleen'. For example, the text Zheng Zhi Ji Yao (A Collection of Patterns and Treatments) states that 'if digested food is unable to transform, there is a Spleen disorder and treatment should tonify the Spleen. However, if a patient is reluctant to eat but feels comfortable after eating, it is a Stomach disorder'.

The Stomach is a fu organ and receives food and water. There are numerous factors that can affect the Stomach: exogenous pathogens, emotions and Stomach qi weakness. For example, if the Stomach is invaded by exogenous pathogens such as summer-heat, damp or phlegm-damp, they cause internal blockages. If the Stomach qi is deficient the Stomach will not be able to receive food. Stomach fluid is Stomach yin and Stomach qi is Stomach yang. Clinically, a Stomach fluid (yin) and Stomach qi (yang) deficiency can cause a poor appetite with no desire to eat.

The transformation of food into food essence depends upon the function of the Spleen. Once transformed, food essence is then transported and dispersed to the zangfu, four extremities, bones and other parts of the body. If the Spleen's transportation function is deficient, the food remains in the Stomach and cannot be digested causing abdominal distention and indigestion. If the Spleen is deficient and unable to transport and disperse food essence, yuan qi will be insufficient and the whole body will be lethargic.

Treatment strategy: If the patient has a poor appetite and indigestion but no abdominal distention after eating, it indicates that the transportation and transformation function is normal, but that the receiving of food is abnormal. Harmonise the Stomach with the formula Er Chen Tang (Two-Cured Decoction). Modify according to the pattern: hot, cold, deficiency, excess, yin and yang, i.e. add Bai Dou Kou (Amomi rotundus Fructus), Mai Ya (Hordei Fructus germinantus), Dao Ya (Oryzae Fructus germinantus), Sha Ren (Amomi Fructus), Shen Qu (Massa medicata fermentata) and Bian Dou (Lablab Semen album).

If the main complaint is food retention with indigestion, abdominal distention and an aversion to excessive eating, but there is a good appetite with no nausea after eating, then the Stomach function is normal and the Spleen is abnormal. Strengthen the Spleen and assist the transformation and transportation function by using the formula Liu Jun Zi Tang (Six Gentleman Decoction). Additional herbs that can be added include Sha Ren (Amomi Fructus), Gan Jiang (Zingiberis Rhizoma), Zhi Ke (Aurantii Fructus) and Yi Zhi Ren (Alpiniae oxyphyllae Fructus) etc. They are pungent, sweet and warm in nature and strengthen the Spleen qi.

If both the Spleen and Stomach function is abnormal, the practitioner must treat both but analyse which organ is weaker and which stronger. Some herbs can treat both the Spleen and Stomach at the same time. For example the classical text Bi Hua Yi Jing states that 'Bai Zhu (Atractylodis macrocephalae Rhizoma), Bian Dou (Semen Dolichoris Lablab), Shan Yao (Dioscoreae Rhizoma), Zhi Ke (Aurantii Fructus), Zhi Shi (Aurantii Fructus Immaturus), Shen Qu (Massa medicata fermentata), Sha Ren (Amomi Fructus), Gan Jiang (Zingiberis Rhizoma) and Gan Cao (Glycyrrhizae Radix) can treat both the Spleen and Stomach.'

Ascending and descending functions

The Spleen is a yin zang that governs ascending. The Stomach is a yang fu that governs descending.

The Spleen carries the clear essence of food up. If this function is impaired and qi stagnates in the middle jiao, a person may experience indigestion, abdominal distention and chronic diarrhoea. In acute cases use Xiang Sha Liu Jun Zi Tang (Six-Gentleman Decoction with Aucklandia and Amomum) and Liu Jun Zi Tang (Six-Gentleman Decoction) with Bai Dou Kou (Amomi Fructus rotundus), Gan Jiang (Zingiberis Rhizoma), Huang Qi (Astragali Radix), Hou Po (Magnoliae officinalis Cortex), Zhi Shi (Aurantii Fructus Immaturus) and Zhi Ke (Aurantii Fructus), etc., all of which are pungent, sweet and warm in nature and help the Spleen's ascending function.

If Spleen qi fails to ascend upwards, the qi will descend causing chronic diarrhoea with prolapse of the rectum, uterus and lower abdomen with haemorrhoids. If the Spleen qi descends, use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) or Sheng Yang Yi Wei Tang (Raise the Yang and Benefit the Stomach Decoction) to raise the clear qi and stop diarrhoea.

The Stomach's function is to descend. Factors that inhibit this include exogenous pathogenic factors, diet, emotions, the Liver overwhelming, phlegm, qi and blood disharmonies, etc. If Stomach qi fails to descend, this can result in the following three disorders:

Stomach qi fails to descend: If Stomach fluid is damaged it cannot moisten the Stomach. This causes a failure of the descending function manifesting as a poor appetite, deficient glomus with inability to eat, constipation or dry stools and difficulty in defecating. Use sweet, cool and moist herbs to tonify the Stomach yin and induce the Stomach qi to descend. For example Mai Men Dong (Ophiopogonis Radix), Gua Lou Ren (Trichosanthis Semen), Sha Shen (Glehniae Radix), Yu Zhu (Polygonati odorati Rhizoma), Shi Hu (Dendrobii Herba), Huo Ma Ren (Cannabis Semen) and Tian Hua Fen (Trichosanthis Radix).

Stomach qi fails to descend with turbidity: If the Stomach qi fails to descend and turbid qi cannot descend, the patient may complain of chest and Stomach distention, inability to eat and nausea. If the Stomach fluid is not damaged, harmonise the Stomach and promote the yang qi by using the formula Er Chen Tang (Two Cured Decoction), plus herbs such as Hou Po (Magnoliae officinalis Cortex), Zhi Shi (Aurantii Fructus Immaturus), Gan Jiang (Zingiberis Rhizoma), Huo Xiang (Pogostemonis/ Agastaches Herba), Bai Dou Kou (Amomi Fructus rotundus), Su Geng (Perillae Caulis) etc. Or use the formula Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium) which is pungent and bitter in nature and helps the qi to disperse and descend.

Stomach qi cannot descend with rebellious qi: The symptoms in this category include vomiting, belching, hiccups, nausea, etc. The treatment strategy is to harmonise the Stomach and descend the rebellious qi. Formulas that can be prescribed include Wen Dang Tang (Warm the Gallbladder Decoction) or Ju Pi Zhu Ru Tang (Tangerine Peel and Bamboo Shaving Decoction from Formulas to Aid the Living) or Xuan Fu Dai Zhe Tang (Inula and Haematite Decoction). Modify according to hot or cold patterns with the main strategy being to descend the Stomach qi.

Dry and damp patterns

According to wu xing theory, the Spleen is damp earth and dislikes dampness, while the Stomach is dry earth and dislikes dryness. During the Ming dynasty the physician Fang Guang stated that 'the Spleen dislikes dampness and prefers dryness'. Therefore many formulas use drying herbs to eliminate dampness in the Spleen. However, when Stomach fire flares upwards with symptoms of a dry mouth and throat, inability to eat and hiccups, use herbs to moisten the Stomach.

Stomach dryness patterns Stomach dryness can be caused by several factors:

• Febrile disease can damage the Stomach fluid.
• Chronic disease can cause a yin deficiency.
• The use of strong diuretic herbs can injure the yin.
• The wrong use of herbs, i.e. hot or dry herbs can also injure the yin.

If the Stomach fluid is damaged and cannot moisten, it is categorised as Stomach dryness, with symptoms of a dry red tongue, thin pulse, dry mouth, dry or hard stools, thirst, fullness, poor appetite, no desire for food when hungry, and Stomach ache/pain. In these cases pungent, warm, dry, aromatic, qi regulating herbs will have no effect and may worsen the pain. The correct treatment strategy is to use sweet, cooling, moisturising herbs. Use the formula Yu Zhu Mai Men Dong Tang1, first recorded in the classical text Wen Bing Tiao Bian (Systematic Identification of Warm Diseases). In cases of Stomach dryness with pain and dry stools use Yi Guan Jian (Linking Decoction). If the bowel movements become drier, harder and difficult to pass then promote the fluids and moisten the bowels by adding Sheng Di Huang (Rehmanniae Radix), Mai Men Dong (Ophiopogonis Radix), Xuan Shen (Scrophulariae Radix), Huo Ma Ren (Cannabis Semen), Gua Lou Ren (Trichosanthis Semen), Xing Ren (Armeniacae Semen), Bai Zi Ren (Platycladi Semen), etc. If these are administered and the stools are still difficult to pass add Sheng Shou Wu (Raw Polygoni multiflori Radix).

Spleen dampness patterns

The main symptoms of Spleen dampness include diarrhoea, abdominal distention and fullness with a thick, or watery, greasy tongue coating. In these patterns, use bitter, warm or pungent herbs to dry dampness and strengthen the Spleen, for example Ping Wei San (Calm the Stomach Powder). To promote diuresis and resolve dampness use mainly sweet and bland herbs such as Fu Ling (Poria), Hua Shi (Talcum), Che Qian Zi (Plantaginis Semen), Yi Yi Ren (Coicis Semen), and Tong Cao (Tetrapanacis Medulla). To transform dampness, use aromatic herbs such as Huo Xiang (Pogostemonis/Agastaches Herba) and Pei Lan (Eupatorii Herba). Wind expelling herbs can also be used to dry dampness such as Fang Feng (Saposhnikoviae Radix), Qiang Huo (Notopterygii Rhizoma seu Radix) and Du Huo (Angelicae pubescentis Radix), etc. If there is damp heat, add bitter and cold herbs that can dry dampness and clear heat, such as Huang Lian (Coptidis Rhizoma), Xia Ku Cao (Prunellae Spica) and Huang Qin (Scutellariae Radix), etc. If there is cold damp add Wu Zhu Yu (Evodiae Fructus), Gan Jiang (Zingiberis Rhizoma), Cao Dou Kou (Alpiniae katsumadai Semen), Yi Zhi Ren (Alpiniae oxyphyllae Fructus), etc.

Spleen, Stomach and Liver

Liver qi exploits the stomach

Stomach is earth and the Liver is wood. When the Liver exploits the Stomach it is like wood growing up into and through the earth, a form of counter-action. There are three types of disharmony within this category.

Liver fire exploits the Stomach

Here the main symptoms include acid regurgitation, nausea and epigastric pain. In such instances use a formula to disperse the Liver and harmonise the Stomach such as Er Chen Tang (Two-Cured Decoction) plus Jin Ling Zi Tang (Melia Toosendan Decoction) and Zuo Jin Tang (Left Metal Deoction) or use Er Chen Tang (Two-Cured Decoction) with Wu Mei (Mume Fructus), Huang Lian (Coptidis Rhizoma) and Chuan Jiao (Zanthoxyli Pericarpium), etc, which makes up the formula Wu Mei An Wei Wan2 (Harmonise the Stomach Pill with Mume). During the Qing dynasty, the physician Wang Xu Gao was recorded as stating that 'the use of bitter, pungent and sour herbs can disperse Liver fire and inhibit its invasion into the Stomach'.

Liver qi stagnates then exploits the Stomach

The main symptoms of this pattern include epigastric and hypochondriac pain and distention and belching. These symptoms are related to emotional upsets. The treatment strategy should soothe the Liver and harmonise the Stomach. Use the formula Si Ni Tang (Frigid Extremities Decoction). Additional herbs that can be added include Gui Zhi (Cinnamomi Ramulus), Qing Pi (Citri reticulatae viride Pericarpium), Chen Pi (Citri reticulatae Pericarpium), Xiang Fu (Cyperi Rhizoma), Ban Xia (Pinelliae Rhizoma preparatum) and Bai Dou Kou (Amomi Fructus rotundus).

Stomach yin depletion allows Liver qi to exploit

In this category the main symptoms include prolonged epigastric pain, dry stools, dry mouth and a deep red tongue. The use of warm, pungent herbs to regulate qi will make the symptoms worse because the Liver is a hard organ and needs herbs to soften and harmonise it.

The treatment strategy should be directed towards softening the Liver and nourishing the Stomach yin. Use Yi Guan Jian (Linking Decoction) or Di Ding Tang3, which nourishes the Stomach yin and Stomach qi, controls the Liver, stops pain and vomiting and regulates qi. These formulas are not too dry and nourish the yin without being too greasy. If there is constipation remove Wu Wei Zi (Schisandrae Fructus) and Wu Mei (Mume Fructus) as they astringe.

The Liver qi exploits the Spleen's deficiency

In this category the Spleen is primarily deficient and allows itself to be exploited by the Liver qi. The main manifestations include diarrhoea, abdominal distention and pain:

Diarrhoea: When a deficient Spleen allows itself to be invaded by the Liver with symptoms of diarrhoea, it is by definition a chronic condition. Other symptoms will include abdominal pain, the need to defecate accompanied by pain which is relieved after defecating. During the Ming dynasty it was stated in the text Yi Fang Kao (Medical Remedies Researched) that 'the pain is caused by the Liver while the diarrhoea is caused by the Spleen'. The Liver disease is primarily characterised by excess and therefore exploits the deficient Spleen. In such cases use Tong Xie Yao Fang (Important Formula for Painful Diarrhoea) to control wood and assist earth. Prof. Shi likes to use the physician Li Dong Yuan's formula Sheng Yang Yi Wei Tang (Raise the Yang to Benefit the Stomach Decoction) and add or remove herbs to tonify qi, ascend yang qi and strengthen the Spleen to remove dampness. If the abdominal pain is severe add Rou Gui (Cinnamomi Cortex) and Wu Zhu Yu (Evodiae Fructus). For diarrhoea, it is also possible to use Pao Jiang (Zingiberis Rhizoma preparata) instead of Sheng Jiang (Zingiberis Rhizoma recens).

Abdominal distention and pain: Many pathogenic factors can cause abdominal distention and pain, the most common of which is Liver qi invading the Spleen. In the Qing dynasty, Hua Xiu-Yun stated that 'the Liver exploits the Spleen causing abdominal distention'. Sometimes the patient will have alternating constipation or loose stools. Abdominal distention is caused by a failure of the Spleen's role in transformation and transportation. Deficient cold and qi dissipating also causes distention. The main treatment strategy is to strengthen the Spleen to assist its transportation function. If this is not successful, add sour herbs to soothe the Liver thus inhibiting its invasion into the Spleen. Use the formulas Li Zhong Tang (Regulate the Middle Decoction) and Liu Jun Zi Tang (Six Gentlemen Decoction). It is also possible to add Bai Shao (Paeoniae Radix Alba), Rou Gui (Cinnamomi Cortex), Mu Gua (Chaenomelis Fructus), Wu Mei (Mume Fructus) etc. For abdominal pain due to Spleen and Stomach deficient cold, warm the middle jiao and regulate qi. If this is not effective use Liu Jun Zi Tang (Six- Gentlemen Decoction) and Wu Zhu Yu (Evodiae Fructus), Rou Gui (Cinnamomi Cortex), Bai Shao (Paeoniae Radix Alba), Mu Xiang (Aucklandiae Radix) and Chuan Jiao (Zanthoxyli Pericarpium). If this is still not effective, then change the main formula to Huang Qi Jian Zhong Tang (Astragalus Decoction to Construct the Middle). If this again is not successful use Xiao Chai Hu Tang (Minor Bupleurum Decoction) and Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) plus and minus various herbs. Clinically, Prof. Shi likes to use Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) plus Xiao Chai Hu Tang (Minor Bupleurum Decoction), modified, for hunger pains relieved by eating, epigastric discomfort with excessive eating and an aversion to cold food.

Spleen, Stomach and Kidney

According to wu xing theory, the Spleen and Stomach are earth. The Kidney has two characteristics, fire (Kidney yang, the gate of vitality, which warms) and water (Kidney yin). In Spleen and Stomach disorders, some common patterns of the Spleen, Stomach and Kidney's pathomechanisms are related.

Spleen, Stomach and Kidney yang deficiency Fire generates earth because Kidney yang can warm the Spleen earth. When the Stomach and Spleen yang qi are deficient, the practitioner should tonify not only the Spleen and Stomach but also warm and nourish the Kidney yang. This method is known as tonifying fire to generate earth.

Chronic diarrhoea: When the Spleen, Stomach and Kidney are deficient there will be symptoms of chronic diarrhoea and distention. The chronic diarrhoea presents as loose stools as well as undigested food. Symptoms will include four limbs that are cold and tire easy, pale tongue and face, a lack of shen, an aversion to cold and wind and a thin, small, deep pulse. During the consultation the physician should ask the patient if there is any undigested food present in the stools. This may indicate that the patient has a deficiency of Kidney fire. The treatment strategy should warm and tonify Kidney yang. Use Fu Zi Li Zhong Wan (Prepared Aconite Pill to Regulate the Middle) plus Si Shen Wan (Four-Miracle Pill). If the tongue is tender (fresh), use Pi Shen Shuang Bu Wan4 to tonify the Spleen and Kidney. The practitioner can also use Wei Guan Jian (5). Additionally add Rou Dou Kou (Myristicae Semen) and Bu Gu Zhi (Psoraleae Fructus) to tonify the Kidney.

Abdominal distension: When the Spleen and Stomach yang are deficient, the main symptoms will include a poor appetite, epigastric distension which is worse after eating, an aversion to cold food, an aversion to cold, a white tongue coating and a deep, thin pulse. Use the formula Li Yin Jian6 plus Bai Zhu (Atractylodis macrocephalae Rhizoma), Dang Shen (Codonopsitis Radix), Sha Ren (Amomi Fructus), Cao Dou Kou (Alpiniae katsumadai Semen) and Mu Xiang (Aucklandiae Radix) to warm and tonify the Spleen and Kidney.

The physician Yu Ting-Hong stated in the text Zhen Yu Ji (Medical Case Records of Yu Ting Hong), that 'in deficient distention cases use herbs to warm and tonify the Spleen and Kidney', for example Huang Qi (Astragali Radix), Bai Zhu (Atractylodis macrocephalae Rhizoma), Ren Shen (Ginseng Radix), Fu Zi (Aconiti Radix lateralis preparata), Rou Gui (Cinnamomi Cortex), Ba Ji Tian (Morindae officinalis Radix), Tu Si Zi (Cuscutae Semen), Gou Qi Zi (Lycii Fructus), Shu Di (Rehmanniae Radix preparata), Du Zhong (Eucommiae Cortex), Yi Zhi Ren (Alpiniae oxyphyllae Fructus) and Bu Gu Zhi (Psoraleae Fructus). Clinically, therefore, for deficiency distension a practitioner should use tonifying herbs accompanied by symptoms of obstruction, a therapeutic method contrary to the usual strategy. Another physician Yan Yong-He stated in the text Ji Sheng Fang that 'tonifying the Spleen method is inferior to tonifying the Kidney'.

Spleen, Stomach and Kidney yin deficiency: Spleen and Stomach disorders have four different patterns: yin, yang, heat and cold. If there is a Spleen and Stomach yin deficiency, invigorate and nourish Kidney yin. The physician Gao Gu- Feng stated that 'if the Kidney is vigorous then the Stomach yin will be abundant'. Another physician Jiang Wen Zhai stated that 'tonifying the Kidney can help the appetite and the Stomach function'. If there is Stomach pain due to Stomach yin deficiency, nourish the Liver and Kidney yin. For example, in cases of dysphagia with a Kidney yin deficiency leading to the Spleen and Stomach's fluid to dry out, it will be unable to moisten with food being difficult to pass down. The patient will usually be thin and the stools like pellets. Use the formula Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia). However, if there is a case where a patient has Kidney yin deficiency which causes a deficiency of Stomach yin and the treatment strategy used does not nourish the Kidney yin, the treatment will not be successful. Use the formula Yi Guan Jian (Linking Decoction) or Shu Gan Yi Shen Tang [Liu Wei Di Huang Tang plus Chai Hu (Bupleuri Radix) and Bai Shao (Paeoniae Radix alba)].

Spleen, Stomach and Heart

The Heart is fire and in general fire generates earth. However, clinically if the Spleen and Stomach yang is deficient it is necessary to tonify fire to generate earth as mentioned in the discussion on Spleen, Stomach and Kidney yang deficiency. To generate Spleen earth, one should tonify Kidney fire. To generate Stomach earth, one should tonify Heart fire. If there is a Stomach deficiency with prolonged epigastric pain, use Gui Pi Tang (Restore the Spleen Decoction) or Miao Xiang San (Marvellously Fragrant Powder) to warm and tonify the Heart and Spleen. If there is poor appetite, epigastric distention after eating and diarrhoea caused by Spleen or Stomach deficiency, Prof. Shi believes that tonifying the Kidney fire is a better method. If there is Heart blood deficiency, one can also warm and tonify Heart fire. If there is excessive Heart fire it can lead to a Spleen and Stomach disorder with symptoms such as irritability, palpitations, insomnia, mouth ulcers and a thin, rapid pulse. In such cases use Tian Wang Bu Xin Tang (Emperor of Heaven's Special Decoction to Tonify the Heart) to nourish Heart yin.

Differentiating yin and yang patterns

In yin and yang theory, zang is yin and fu is yang; Spleen is yin earth and Stomach is yang earth, although the Spleen and Stomach both have yang and yin. This is useful in clinical pattern differentiation and when devising a treatment strategy.

Stomach yang deficiency A deficiency of Stomach yang can be due to irregular eating either too much or too little internal injuries due to the consumption of cold food, emotional upsets, or overwork, all of which result in the impairment of Stomach yang, causing deficiency cold in the Stomach. Symptoms will include an aversion to cold food, a poor appetite, Stomach distention or pain, rebellious Stomach qi such as nausea, vomiting, dyspepsia, pale tongue with a white coating and a deep, thin, small pulse. In such cases use Li Zhong Tang (Restore the Middle Decoction) and Liu Jun Zi Tang (Six-Gentlemen Decoction), plus Ding Xiang (Flos Caryophylli), Bai Dou Kou (Fructus Amomi Kravanh) and Sha Ren (Fructus Amomi). If there is severe cold add Bi Ba (Fructus Piperis Longi), Bi Cheng Qie (Fructus Cubebae), Gao Liang Jiang (Rhizoma Alpiniae Officinari) and Rou Gui (Cortex Cassiae Cinnamomi).

Stomach yin deficiency A deficiency of Stomach yin is associated with a deficiency of fluids. Symptoms will include a poor appetite, no feeling of hunger or feels hunger but eats a little, burning Stomach pain, a dry mouth, thirst, irritability, dry stools, dark red tongue and a thready, rapid pulse. In these cases, use sweet, cool herbs to generate fluids, while sweet and sour herbs can generate yin. Use Yu Zhu Mai Men Tang plus Sheng Di (Radix Rehmanniae Glutinosae), Shi Hu (Herba Dendrobii), Mai Men Dong (Tuber Ophiopogonis Japonici), Bai Shao (Radix Paeoniae Lactiflorae), Wu Mei (Fructus Pruni Mume) and Bai Bian Dou (Semen Dolichoris Lablab). If there is Stomach pain, use a modified version of Yi Guan Jian (Linking Decoction).

Spleen yang deficiency The Stomach depends upon the Spleen yang's warmness to function correctly; the Stomach is then able to perform its function of rotting and ripening water and grain.

The main Spleen yang deficient symptoms can be seen in the dysfunction of the transformation and transportation actions; severe abdominal distention after eating, qi stagnation in the middle Jiao, epigastric pain or distension, all indicate that the Spleen is not able to ascend the clear qi. Instead it descends, with diarrhoea and smaller abdomen or rectal prolapse. The Spleen controls the four extremities, if the Spleen yang is deficient the symptoms will manifest as four cold extremities, a pale complexion, tiredness, moderate, week or thin and deep pulse and a slightly white tongue coating. Sweet and warm herbs can tonify qi, whilst pungent and sweet herbs can regulate yang. Use the formula Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction), Li Zhong Tang (Restore the Middle Decoction), Xiang Sha Liu Jun Zi Tang (Six-Gentlemen Decoction with Aucklandia and Amomum), Huang Qi Jian Zhong Tang (Astragalus Decoction to Construct the Middle), Sheng Yang Yi Wei Tang (Raise the Yang and Benefit the Stomach Decoction), etc. For regulating qi add Mu Xiang (Radix Aucklandiae Lappae), Hou Po (Cortex Magnoliae Officinalis), Qing Pi (Pericarpium Citri Reticulatae Viride), Chen Pi (Pericarpium Citri Reticulatae), Zhi Ke (Fructus Citri Aurantii), Zhi Shi (Fructus Immaturus Citri Aurantii), etc. For warming the Spleen add Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata), Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), Cang Zhu (Rhizoma Atractylodis), Pao Jiang (Quick-fried Rhizoma Zingiberis Officinalis), etc.

In the late Qing dynasty the physician Tang Rong-Chuan stated in the text Xue Zheng Lun Nan Yu Yi Tong Lun that to harmonise and treat the Spleen and Stomach, the practitioner should differentiate between yin and yang. After the physician Li Dong-Yuan's teachings, physicians were aware that they should tonify Spleen yang in severe Stomach and Spleen disorders but were unaware they had to tonify Spleen yin as well. When Spleen yang is deficient, grain and water can absolutely not be transformed. When the Spleen yin is deficient, grain and water can also not be transformed. For Spleen deficient patterns use warm herbs to promote the appetite and cold herbs to subdue the appetite. Tonifying yang herbs include Gan Jiang (Rhizoma Zingiberis Officinalis), Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata), etc, which promote the appetite. Tonifying Spleen yin herbs include Zhi Mu (Rhizoma Anemarrhenae Asphodeloidis) and Shi Gao (Gypsum), etc, which act to generate fluids.

Generally, Spleen yin deficient symptoms will manifest as dysphasia, constipation, abdominal distention, dry mouth, hot feeling in the hands and feet, irritability, dry skin, yellow complexion and a thin body. The tongue will be red or pale and young with a little or dry coating. The pulse will be soft and thin or thin and rapid. Prof. Shi often uses Zi Yin Jian Pi Wan7 and sometimes adds Shen Ling Bai Zhu San (Ginseng, Poria and Atracylodes Macrocephala Powder) to tonify the Spleen yin. To treat Spleen yin deficient symptoms such as diarrhoea, it is also possible to use Ba Zhen Tang (Eight-Treasure Decoction).

Differentiating hot and cold patterns

There are three types of hot and cold patterns.

Spleen and Stomach deficient cold Most symptoms in this category are associated with a Spleen and Stomach yang deficiency leading to internal cold. The symptoms include a reduced food intake, Stomach and abdominal cold pain, a comfortable feeling after consuming a little amount of food and distention after consuming too much food, indigestion, diarrhoea, pale complexion, tiredness, an aversion to cold, pale tongue with a white coating and a soft, thin pulse. If the Spleen and Stomach deficient cold is mild use pungent, warm herbs to expel the cold and pungent, sweet herbs to rectify yang. The main formula for this pattern is Liu Jun Zi Tang (Six- Gentleman Decoction). Additionally add Gan Jiang (Rhizoma Zingiberis Officinalis), Cao Dou Kou (Semen Alpiniae Katsumadai) and Yi Zhi Ren (Fructus Alpiniae Oxyphyllae) to warm the Spleen and Stomach. If this treatment strategy is not effective and the distension and pain become worse, the Nei Jing (Plain Questions) states, 'when cold pathogen attacks internally use pungent and warm herbs and bitter and sweet herbs to assist'. Prof. Shi uses the formula Fu Yang Zhu Wei Tang8 in Spleen and Stomach deficient cold patterns with abdominal distending pain and loose stools. However, if one has internal heat this formula can induce Stomach fire rising upwards causing a dry mouth and throat, mouth and tongue ulcers and tooth ache. In such cases, replace the formula with Li Yin Jian6, which warms and moistens plus additional herbs to warm the Spleen yang. If the main symptom is Stomach pain due to Spleen and Stomach deficient cold and the pain is aggravated by hunger but is relieved by eating with an aversion to cold food, along with distension after excessive eating, use the formula Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) plus Xiao Chai Hu Tang (Minor Bupleurum Decoction). If it is serious use Liang Fu Wan (Galangal and Cyperus Pill).

Spleen and Stomach damp heat This can be caused by a deficiency of Spleen and Stomach qi as well as internal injury caused by food intake causing damp heat. Other causes include external pathogenic factors such as damp heat. The patient will have an aversion to food, stuffiness of the epigastrium and abdominal regions, epigastric pain, a dry, bitter, sticky mouth, loose stools and ungratifying defecation. The tongue will have a thick, greasy, yellow coating. If damp heat injures yin the tongue will be red. In these cases use herbs to resolve dampness, clear heat and rectify the Spleen and Stomach dampness or regulate qi to remove stagnation and clear heat. Use the formula Yue Ju Tang (Escape Restraint Decoction), plus Huang Lian (Rhizoma Coptidis), Huang Qin (Radix Scutellariae Baicalensis), Qing Pi (Pericarpium Citri Reticulatae Viride) and Chen Pi (Pericarpium Citri Reticulatae). If there is severe heat add Sheng Shi Gao (Gypsum), Zhi Mu (Rhizoma Anemarrhenae Asphodeloidis) and Zhu Ru (Caulis Bambusae in Taeniis), etc.

Spleen-Stomach hot and cold combination This pattern, commonly seen in clinical practice, is caused by the Spleen and Stomach originally having a deficient cold pattern and if this stagnates for a long period of time it causes heat, therefore this disorder has hot and cold pattern combinations. Symptoms include epigastric distension, a reduced food intake, an aversion to cold food, with the distention and pain becoming worse after consuming cold food, with heartburn and a dry mouth with a bitter taste. Use pungent, warm and bitter cold formulas such as Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium). For severe Stomach distension add Zhi Ke (Fructus Citri Aurantii) and Cao Dou Kou (Semen Alpiniae Katsumadai). If there is Stomach pain use Ban Xia Xie Xin Tang (Pinellia Decoction to Drain the Epigastrium) and Yue Tao San9, plus Jin Ling Zi San (Melia Toosendan Powder). If there is acid regurgitation use Zuo Jin Wan (Left Metal Pill) plus Duan Wa Leng Zi (Fried Concha Arcae) and Qing Pi (Pericarpium Citri Reticulatae Viride). The physician Zhu Dan Xi stated that 'to treat Stomach pain use pungent and warm herbs to rectify the Stomach and Spleen'. Add Shan Zhi Zi (Fructus Gardeniae Jasminoidis) and Huang Lian (Rhizoma Coptidis), etc, which are bitter and cold and clear heat.

Differentiating excess and deficiency

Deficient patterns have already been discussed. Excess patterns can include a number of factors such as summer heat damp invading the body or an invasion by pathogenic cold. Symptoms will include a torpid intake, nausea, vomiting, or epigastric pain and loose stools.

Summer heat damp When summer heat damp invades the body use Huo Xiang Zheng Qi Tang (Agastache Decoction to Rectify the Qi), plus Huang Lian (Rhizoma Coptidis) and Huang Qin (Radix Scutellariae Baicalensis) to clear heat and resolve dampness.

Exterior pathogenic cold An invasion by exterior pathogenic cold will include symptoms such as vomiting clear fluids, epigastric pain, abdominal distension and diarrhoea. Use Li Zhong Tang (Regulate the Middle Pill). For severe cold pain add Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata). If there is diarrhoea use Wei Ling Tang (Calm the Stomach and Poria Decoction).

Retention of food The retention of food can be caused by an improper diet or the existence of a previous Spleen and Stomach disorder. It can be associated with either an excess or deficiency, but this is mainly a branch, excess pattern. Symptoms will include distension, pain in the epigastrium, nausea, vomiting, foul breath, sour regurgitation or diarrhoea and indigestion. The retention of food can be broken down into a further three patterns:

Deficient cold: With Spleen and Stomach deficient cold and the impairment of the transformation and transportation function due to food intake, use Bao He Wan (Preserve Harmony Pill from the Precious Mirror). Do not use Lian Qiao (Fructus Forsythiae Suspensae) because it is pungent and cool, instead add Bai Zhu (Rhizoma Atractylodis Macrocephalae), Zhi Ke (Fructus Citri Aurantii) and Gan Jiang (Rhizoma Zingiberis Officinalis), etc. Or use Dou Kou Ju Hong San10 and modify it.

Internal heat: With internal heat caused by an improper diet, use Da An Tang (Great Tranquility Decoction), plus Huang Lian (Rhizoma Coptidis) with Huang Qin (Radix Scutellariae Baicalensis).

Phlegm damp: When phlegm damp stagnates in the Spleen and Stomach it causes chest and Stomach excess and stuffiness, nausea and the vomiting of phlegm and sometimes Stomach pain. Use Er Chen Tang (Two-Cured Decoction) or Fu Ling Yin11, or use Xiao Ban Xia Jia Fu Ling Tang or He Wei Er Chen Jian (Er Chen Tang plus Gan Jiang (Rhizoma Zingiberis Officinalis) and Sha Ren (Fructus Amomi) to resolve phlegm and harmonise the Stomach.

Root deficiency and branch excess

In these cases assist the digestion to reduce the branch (xiao bu fa). The root pattern is a Spleen and Stomach deficiency. The patient will experience Stomach and abdominal distention with reduced food intake or will complain of loose stools and tired extremities. Use a formula such as Zhi Shi Li Zhong Tang (Immature Bitter Orange Decoction to Regulate the Middle) or Jia Wei Zhi Zhu Tang (Modified Immature Bitter Orange and Atractylodes Macrocephala Decoction). If there is excessive distention due to damage caused by food, add Lai Fu Zi (Semen Raphani Sativi) and Ji Nei Jin (Endothelium Corneum Gigeriae Galli). If the cold is severe add Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata) and Gan Jiang (Rhizoma Zingiberis Officinalis). For heat add Huang Lian (Rhizoma Coptidis) and Huang Qin (Radix Scutellariae Baicalensis).

It is necessary to differentiate between excess and deficient patterns in cases of epigastric distension. In protracted diseases due to a Spleen and Stomach deficiency, if the treatment strategy of regulating qi to dissipate qi or dispersing formula still allows the disorder to be present, then consider that the distention is caused by a deficiency pattern.

Excess distention is caused by qi stagnation; in such cases use pungent and dissipating herbs. Deficiency distention is caused by qi dissipating. The treatment strategy should be to use sour herbs to astringe. If formulas which are sweet and warm are used to invigorate qi and tonify the Spleen causing the distention to become severe, it should be considered that the distention is an excessive type. After treatment it is usually possible to differentiate if the pattern is either excessive or deficient after a reaction to the previously prescribed formula.

For deficiency distention pattern, if Xiang Sha Liu Jun Zi Tang (Six Gentleman Decoction with Aucklandia and Amomum) or Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) are not effective then not only can a practitioner use sour herbs to astringe, but also herbs to warm and nourish the Kidney fire or warm and tonify the Spleen and Kidney. Therefore, it can be said, that tonifying the Spleen is inferior to tonifying the Kidney.

Differentiating qi and blood patterns

Spleen and Stomach qi deficiency When the Spleen and Stomach yang qi is deficient, the transformation and transportation will be dysfunctional with symptoms of abdominal distension, epigastric pain, reduced food intake, diarrhoea, loose stools, weak four extremities, pale complexion and a thin, soft pulse. Use Shen Ling Bai Zhu San (Ginseng, Poria and Atractylodes Macrocephala Powder from the Analytic Collection). If the Spleen and Stomach is deficient with a deficiency of yuan qi and lassitude, use Si Jun Zi Tang (Four Gentleman Decoction), plus Huang Qi (Radix Astragali Membranacei) and Shan Yao (Radix Dioscoreae Oppositae). If there is pain add Rou Gui (Cortex Cinnamomi Cassiae), Bai Shao (Radix Paeoniae Lactiflorae), Xiang Fu (Rhizoma Cyperi Rotundi), Gao Liang Jiang (Rhizoma Alpiniae Officinari) and Wu Yao (Radix Linderae Strychnifoliae), etc. If tonifying the Spleen and Stomach formula is not effective use a tonifying Kidney formula. Use herbs such as Tu Si Zi (Semen Cuscutae Chinensis), Shu Di Huang (Radix Rehmanniae Glutinosae Conquitae) and Bu Gu Zhi (Fructus Psoraleae Corylifoliae) to warm the lower jiao.

Spleen and Stomach qi stagnation

The pathogenic factors that cause Spleen and Stomach qi stagnation include summer heat damp, wind-cold or internal injury due to the consumption of cold, greasy food along with emotional upset or anger.

All these factors will damage the transportation and transformation function of the Spleen and Stomach, manifesting as abdominal distention, indigestion, foul breath, belching, sour regurgitation or abdominal pain with no desire for food. The bowel movements will be difficult to pass and the tongue will have a thick, greasy coating. Rectify qi and disperse stagnation. Use formulas such as Ping Wei San (Calm the Stomach Powder) and Shen Xiang San12.

If the stagnation transforms into heat with symptoms of a dry mouth, yellow tongue coating and hard stools use Huang Lian (Rhizoma Coptidis), Huang Qin (Radix Scutellariae Baicalensis) and Tian Hua Fen (Radix Trichosanthis Kirilowii). If severe add Da Huang (Radix et Rhizoma Rhei).

Spleen and Heart blood deficiency

Spleen and Heart blood deficiency is a combination of both a deficiency of qi and blood. The commonly seen symptoms include epigastric pain, distention, reduced food intake, tiredness, insomnia, palpitations and a delayed menstruation. When regulating and harmonising the Spleen and Stomach in blood deficiency patterns do not use pungent and warm herbs as they damage yin and blood causing exuberant Stomach fire with depleted Spleen yin. The Stomach and Intestines will become dry with dry and hard stools. The treatment strategy is to nourish and harmonise the Heart and Spleen. Formulas that can be prescribed include Gui Pi Tang (Restore the Spleen Decoction) or Gui Shao Liu Jun Zi Tang13, or use Ba Zhen Tang (Eight-Herb Powder for Rectification) or Shi Quan Da Bu Tang (All Inclusive Great Tonifying Decoction).

Blood stasis causing epigastric pain

In the classics it states that 'pain at the beginning is in the meridians, the meridians govern qi, chronic pain moves into the collaterals and the collaterals control blood'. When protracted epigastric pain does not improve, it moves into the blood level within the collaterals. The treatment strategy should use pungent and moist herbs to unblock the collaterals. Clinically, Prof. Shi's experience is that when the use of qi regulating herbs does not improve the condition, use herbs to quicken the blood and unblock the collaterals and stop the pain. The symptoms of chronic epigastric pain, hypochondriac and back pain tells the practitioner that the disease is in the collaterals. Use herbs such as Dang Gui (Radix Angelicae Sinensis), Tao Ren (Semen Persicae), Bai Zi Ren (Semen Biotae Orientalis), Dan Shen (Radix Salviae Miltiorrhizae), Yu Jin (Tuber Curcumae), Yan Hu Suo (Rhizoma Corydalis Yanhusuo), Wu Ling Zhi (Excrementum Trogopteri seu Pteromi), Hong Hua (Flos Carthami Tinctorri) and Ze Lan (Herba Lycopi Lucidi), etc. If it is a cold pattern add Gui Zhi (Ramulus Cinnamomi Cassiae) and Liang Jiang (Rhizoma Alpiniae Officinari). For heat patterns add Mu Dan Pi (Cortex Moutan Radicis) and Shan Zhi Zi (Fructus Gardeniae Jasminoidis).

For blood stasis patterns as well as using blood quickening herbs, also use qi regulating herbs as qi commands the blood. Include herbs such as Xiang Fu (Rhizoma Cyperi Rotundi), Jiang Xiang (Lignum Dalbergiae Odoriferae), Chen Pi (Pericarpium Citri Reticulatae) and Qing Pi (Pericarpium Citri Reticulatae Viride), etc. Examples of blood quickening formulas include Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansions of Blood Decoction) and Ge Xia Zhu Yu Tang (Drive Out Blood Stasis Below the Diaphragm Decoction). When the stools are black in blood stasis patterns use Da Huang (Radix et Rhizoma Rhei) to remove the blood stasis and produce new blood. When the stools colour turns from black to yellow the treatment has been successful. Clinically, Prof. Shi sometimes sees patients with chronic epigastric pain with unsuccessful treatment and uses Dan Shen Yin (Salvia Decoction) and Dan Shen (Radix Salviae Miltiorrhizae) at 30g each, which he finds very effective.

Conclusion

Clinically, zangfu theory, yin and yang, qi and blood, hot and cold, deficiency and excess have a very close relationship. It is not easy to differentiate and distinguish their mechanisms. A practitioner should understand pattern differentiation from a holistic perspective. Prof. Shi's understanding is that treatment should have different strategies, for example when treating the Stomach and the treatment strategy is not effective, a practitioner should consider that the Liver is exploiting the Stomach and so treat the Liver.

With disorders of the Spleen, if the treatment strategy of treating the Spleen is not responding then treat the Kidney. For example, if Spleen yang is deficient and warming the Spleen yang is not effective then warm the Kidney. If the treatment strategy directed at the qi level is not effective then redirect the strategy to the blood level. For blood stasis patterns differentiate between deficiency and excess. For excessive type blood stasis patterns, quicken the blood and dispel blood stasis. For deficient blood stasis patterns, regulate and nourish qi and blood to dispel blood stasis. If when treating an excessive pattern it is not effective consider that the pattern may be one of deficiency.

In conclusion, bian zheng lun zhi should be used with basic Chinese medical theory to differentiate the pathogenic factors, characteristics, mechanisms and disease, disorder location. When using formulas a practitioner should have a set of strategies that are well thought out. With extensive clinical experience and Chinese medicine theory a practitioner can have good clinical results.

Endnotes

1. Yu Zhu Mai Men Dong Tang: Yu Zhu (Rhizoma Atractylodis Macrocephalae), Mai Men Dong (Tuber Ophiopogonis Japonici), Sha Shen (Radix Ginseng) and Gan Cao (Radix Glycyrrhizae Uralensis). 2. Wu Mei An Wei Wan: Wu Mei (Fructus Mume), Chuan Jiao (Pericarpium Zanthoxyli Bungeani), Fu Zi (Radix Aconiti Lateralis Praeparata), Gui Zhi (Ramulus Cinnamomi), Gan Jiang (Rhizoma Zingiberis), Huang Bai (Cortex Phellodendri), Huang Lian (Rhizoma Coptidis), Chen Pi (Pericarpium Citri Reticulatae), Qing Pi (Pericarpium Citri Reticulatae Viride), Bai Shao (Radix Paeoniae Lactiflorae), Ren Shen (Radix Ginseng), Chuan Lian Zi (Fructus Meliae Toosendan). 3. Di Ding Tang: Sheng Di (Radix Rehmanniae Glutinosae), Ding Xiang (Flos Caryophylli), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Chen Pi (Pericarpium Citri Reticulatae), Hou Po Hua (Flos Magnoliae Officinalis), (milder than Hou Po (Cortex Magnoliae Officinalis), not too dry), Dang Shen (Radix Codonopsitis Pilosulae), Mai Men Dong (Tuber Ophiopogonis Japonici), Wu Wei Zi (Fructus Schisandrae Chinensis), Wu Mei (Fructus Pruni Mume), Gan Cao (Radix Glycyrrhizae Uralensis) and Huang Lian (Rhizoma Coptidis). 4. Pi Shen Shuang Bu Wan: Ren Shen (Radix Ginseng or Dang Shen), Shan Yao (Radix Dioscoreae Oppositae), Lian Rou (Semen Nelumbinis Nuciferae), Sha Ren (Fructus Amomi), Ju Hong (Pars Rubra Epicarpii Citri Erythrocarpae), Shan Zhu Yu (Fructus Corni Officinalis), Ba Ji Tian (Radix Morindae Officinalis), Tu Si Zi (Semen Cuscutae Chinensis), Wu Wei Zi (Fructus Schisandrae Chinensis), Bu Gu Zhi (Fructus Psoraleae Corylifoliae), Rou Dou Kou (Semen Myristicae Fragrantis) and Che Qian Zi (Semen Plantaginis). 5. Wei Guan Jian: Shu Di (Radix Rehmanniae Glutinosae Conquitae), Shan Yao (Radix Dioscoreae Oppositae), Bai Bian Dou (Semen Dolichoris Lablab), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Zhi Gan Cao (Processed Radix Glycyrrhizae Uralensis), Wu Zhu Yu (Fructus Evodiae Rutaecarpae) and Pao Jiang (Quickfried Rhizoma Zingiberis Officinalis). 6. Li Yin Jian: Shu Di (Radix Rehmanniae Glutinosae Conquitae), Dang Gui (Radix Angelicae Sinensis), Gan Jiang (Rhizoma Zingiberis Officinalis) and Zhi Gan Cao (Processed Radix Glycyrrhizae Uralensis). 7. Zi Yin Jian Pi Wan: Dang Shen (Radix Codonopsitis), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Fu Ling (Sclerotium Poriae Cocos), Gan Cao (Radix Glycyrrhizae Uralensis), Mai Men Dong (Tuber Ophiopogonis Japonici), Wu Wei Zi (Fructus Schisandrae Chinensis), Shan Yao (Radix Dioscoreae Oppositae), Shi Hu (Herba Dendrobii), Chen Pi (Pericarpium Citri Reticulatae) and Shan Zha (Fructus Crataegi). 8. Fu Yang Zhu Wei Tang: Ren Shen (Radix Ginseng), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Gan Jiang (Rhizoma Zingiberis Officinalis), Zhi Gan Cao (Processed Radix Glycyrrhizae Uralensis), Shu Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata), Rou Gui (Cortex Cinnamomi Cassiae), Bai Shao (Radix Paeoniae Lactiflorae), Chen Pi (Pericarpium Citri Reticulatae), Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), Wu Zhu Yu (Fructus Evodiae Rutaecarpae) and Cao Dou Kou (Semen Alpiniae Katsumadai). 9. Yue Tao San: Shan Zhi Zi (Fructus Gardeniae Jasminoidis), (cold) and Gao Liang Jiang (Rhizoma Alphiniae Officinari) (hot), 10. Dou Kou Ju Hong San: Ding Xiang (Flos Caryophylli), Mu Xiang (Radix Aucklandiae Lappae), Bai Dou Kou (Fructus Amomi Kravanh), Ren Shen (Radix Ginseng), Hou Po (Cortex Magnoliae Officinalis), Shen Shu, Gan Jiang (Rhizoma Zingiberis Officinalis), Ban Xia (Rhizoma Pinelliae Ternatae), Ju Hong (Pars Rubra Epicarpii Citri Erythrocarpae), Gan Cao (Radix Glycyrrhizae Uralensis), Huo Xiang (Herba Agastaches seu Pogostemi) and Bai Zhu (Rhizoma Atractylodis Macrocephalae). 11. Fu Ling Yin: Ren Shen (Radix Ginseng), Fu Ling (Sclerotium Poriae Cocos), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Zhi Shi (Fructus Immaturus Citri Aurantii), Ju Pi (Pericarpium Citri Reticulatae) and Sheng Jiang (Rhizoma Zingiberis Officinalis Recens). 12. Shen Xiang San: Ding Xiang (Flos Caryophylli), Sha Ren (Fructus Amomi) and Cao Dou Kou (Semen Alpiniae Katsumadai). 13. Gui Shao Liu Jun Zi Tang: Liu Jun Zi Tang (Six-Gentleman Decoction), plus Dang Gui (Radix Angelicae Sinensis) and Shan Yao (Radix Dioscoreae Oppositae).