Chapter Three. Internal heat syndrome and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that reduce heat, relieve fire-toxin, cool the blood and generate the body fluids. They are used to treat various internal heat syndromes.
Causes of internal heat can be divided into external and internal causes:
• Internal heat due to external causes includes exterior wind-cold or exterior wind-heat, which can pass through the exterior region (also referred to as the Wei (Defensive) level in Wei-Qi-Ying-Xue differentiation) and enter the interior regions of the body when the Defensive-Qi is weak or weakened by improper treatment. The heat is increased in pathological development at the Qi, Ying and Xue levels. However, some exogenous pathogenic heat or heat-toxin may rapidly develop into an internal heat syndrome without an obvious onset at the Wei (Defensive) level; this is called latent warm-febrile disease.
• Internal heat due to internal causes includes disturbance of the functions of internal organs, most often caused by emotional upset, chronic diseases, improper diet and medication.
Syndromes in warm-febrile diseases
Warm-febrile disease is a collective name for infectious diseases that are caused by exogenous pathogenic heat in different seasons. The pathogenic changes are characterized by a relatively acute onset, heat predominating at all stages, and damage of body fluids and Yin. In clinical practice, it refers to acute infections caused by bacteria, viruses or other pathogenic microorganisms, such as influenza, pneumonia, bronchitis, gastroenteritis and dysentery.
Pestilence is a type of virulent infectious disease caused by heat-toxins, such as epidemic cerebrospinal meningitis, poliomyelitis and severe acute respiratory syndrome (SARS). The warm-febrile diseases develop in the body at four levels, referred to as Wei, Qi, Ying and Xue. In pestilence cases, there is rarely an initial stage, or a very short initial stage, and the heat or heat-toxin can enter the Qi or Ying level and cause internal heat syndromes directly. The warm-febrile diseases are analyzed and identified by the method of Wei-Qi-Ying-Xue differentiation.
1. Syndrome of heat at the Wei level (the Defensive level)
Heat in the Defensive level is equal to exterior wind-heat syndrome discussed in Chapter 1. Although it does not belong in the internal heat syndrome category, it is mentioned here as a reference to offer a complete overview of febrile diseases.
Manifestations
Main symptoms
Fever, slight aversion to wind and cold, sore throat, slight thirst and sweating.
Secondary symptoms
Headache, general aching of the body, cough.
Tongue
Red border and tip with a yellow and thin coating.
Pulse
Rapid and superficial.
Analysis of the syndrome
This syndrome is the initial stage of a warm-febrile disease and is equal to exterior wind-heat syndrome in Eight Principle Differentiation. The pathogenic factors are wind and heat. Their pathway of invasion is the nose and throat to the Lung. The wind-heat disturbs the function of the Lung and its related regions, the superficial parts of the body. In the differentiation of warm-febrile diseases, the term Wei syndrome indicates that the pathogenic factor is at the Wei level.
• When the Defensive-Qi pits its efforts against the pathogenic factor, there is a fever.
• The opening and closing of pores becomes irregular due to dysfunction of the Lung. The patient may therefore have an aversion to wind and cold, and episodes of slight, irregular sweating may occur.
• Since the throat is the gateway of the Lung, and heat easily injures the fluid, sore throat and thirst may be present.
• When the Lung-Qi fails to disperse and descend, cough starts.
• A red tip and border of the tongue and a superficial and rapid pulse indicate that the wind-heat is in the exterior region.
(See Figure 3.1 on page 114.)
Treatment principle: Expel wind, clear heat, regulate the Lung and release the exterior
Herb selection principles and formula composition strategies
• First, herbs that are cold, pungent or aromatic, enter the Lung meridian and clear wind-heat in the Upper-Jiao are selected.
• Second, herbs that are bitter and cold, enter the Upper-Jiao, clear heat and drain heat by promoting urination are selected.
• Along with herbs in the second group, it is equally important to select slightly pungent and warm herbs that can stimulate the Lung-Qi to expel wind, thereby assisting herbs that clear wind-heat in the Upper-Jiao.
• Herbs that regulate the Lung-Qi so as to assist herbs that clear wind-heat as well as stop cough are often used.
• Herbs that nourish the body fluid and Yin of the Lung should be added if the fluid and Yin of the Lung are injured.
• Herbs that tonify the Qi and Yin should be added in the recovery period.
2. Syndrome of heat at the Qi level
Manifestations
Main symptoms
High fever without chills, perspiration, dry mouth and thirst.
Secondary symptoms
Red face, shortness of breath, scanty urine.
Tongue
Red with a yellow coating.
Pulse
Rapid and forceful.
Associated disorders in western medicine
Acute infections caused by bacteria, viruses or other pathogenic microorganisms.
Analysis of the syndrome
This is the metaphase of warm-febrile diseases. The heat increases inside the body and starts to injure the body fluids. At this level, the heat is very strong and has formed a center in the Lung and Stomach, from where it spreads throughout the entire body. The Qi of the involved organs and regions pits its efforts against the pathogenic heat. The body’s resistance and pathogenic factor are both strong.
• High fever without chill, together with a red face and a rapid and forceful pulse indicate that the heat has already passed the Wei level and entered the Qi level.
• When heat forces the fluid to move out of the body, sweat appears.
• As the intense heat can directly injure the body fluids, patients have intense thirst and a dry feeling in the mouth.
• If the Lung-Qi is unable to disperse and descend properly, there is shortness of breath.
The symptoms and signs at the Qi level are often designated as the Four Extremes, namely extremely high fever, intense thirst, heavy sweating and extremely rapid pulse.
(See Figure 3.2 on page 114.)
Treatment principle: Intensively clear heat, protect the body fluids and vent the pathogenic heat
Herb selection principles and formula composition strategies
• First, herbs that are cold, sweet, salty or pungent, have the function of clearing heat and reducing fire are selected.
• Second, herbs that are sweet and cold, can nourish body fluids and protect the Yin are selected.
• Third, herbs that are pungent and cold, can expel heat, vent heat to the Wei level and eventually eliminate it are used in a small dosage.
CAUTIONS
1. Prevent the development of a smoldering syndrome (hidden-fire syndrome):
The bitter and cold herbs that clear heat should be used with caution. Although they can quickly and strongly clear heat and reduce fire, these herbs cannot be used for a long period of time. With high dosage or long-term usage, patients may develop a smoldering syndrome caused by the side effects of bitter-cold herbs. Because pathogenic heat has a tendency to ascend and cold herbs have a tendency to descend, a severe conflict between cold and heat develops. Cold herbs are able to suppress pathogenic heat when their dosages are very large and the heat has to move downwards. However, as heat does not agree with the cold nature of the herbs, it tries to withdraw but becomes constrained and hides itself in the body. As soon as the patient stops using the cold herbs, the constrained heat is freed from suppression and spreads again. In clinical practice, some chronic infections (e.g. sinusitis, bronchitis, gastroenteritis and urinary tract infection) are the result of using high dosages of cold herbs or antibiotics. Therefore, a small amount of herbs that follow the nature of fire and disperse constrained fire should be used with the bitter and cold herbs in order to clear the heat completely.
2. Protect Yin, Yang and Qi:
Bitter herbs possess a drying property that may injure the Yin of the body, which has already been injured by excess heat. Bitter-cold herbs may injure Stomach-Qi and Yang, and disturb digestion, especially when patients have a weak Spleen or Stomach. Although these herbs should not be used either long term or in large dosages, they can be used together with herbs that protect the Spleen and Stomach.
Structure of the formula and selection of herbs
Chief: Clear heat from the Qi level directly
Shi Gao ( Gypsum)
Shi Gao is pungent, sweet and very cold, and enters the Lung and Stomach meridians. It can powerfully clear heat and reduce fire in the Lung and Stomach, and its pungent nature can disperse the intensive constrained heat. In addition, it can generate body fluids and protect the Yin of the body. It is a perfect ingredient to treat pathological change where the heat is intense at the Qi level.
In a warm-febrile disease, although heat can spread to many organs, Shi Gao, as chief in a formula, clears the heat from the Stomach, the center of Yang and heat of the body, and therefore can effectively reduce heat in the entire body.
Zhi Zi ( Gardeniae fructus) and Ku Zhu Ye ( Bambusae amarae folium)
Zhi Zi is bitter and cold, and enters the San Jiao and Liver meridians. It can be used as chief in the formula if the heat particularly disturbs the Heart and the region of the diaphragm, manifested as irritability, restlessness, insomnia and poor appetite. Zhi Zi can clear the heat and eliminate heat by promoting urination.
Ku Zhu Ye is bitter and cold, and enters the Heart meridian. It can clear the heat in the Heart and increase urination, hence reducing the heat in the Upper-Jiao. It is used if there are symptoms such as irritability, restlessness, a bitter taste in the mouth and scanty urine.
Deputy: Clear the heat, nourish the body fluids and enhance the ability of the chief ingredients
Zhi Mu ( Anemarrhenae rhizoma)
Zhi Mu is bitter and cold but moist in nature. It enters the Lung, Stomach and Kidney meridians. It can nourish the Yin and the body fluids, and clear the heat there. It is often used together with Shi Gao ( Gypsum) and serves as deputy in a formula to enhance the ability of Shi Gao.
Assistant: Nourish the body fluids, clear and disperse the heat, regulate the Qi and reduce the side effect of cold herbs
Sang Ye ( Mori folium) and Pi Pa Ye ( Eriobotryae folium)
Sang Ye and Pi Pa Ye are cold in temperature and both enter the Lung meridian. They can clear the heat and descend the Lung-Qi. They are used when there are symptoms such as cough and shortness of breath due to heat in the Lung. Both are moist in nature. Although they cannot effectively generate the fluid of the Lung, they do not injure this fluid when they regulate the Qi.
Lu Gen ( Phragmitis rhizoma)
Lu Gen is sweet and cold, and enters the Lung and Stomach meridians. It is often used as assistant in the formula to nourish the body fluids, clear heat and relieve thirst. It can soothe the Stomach-Qi and treat nausea and vomiting when heat disturbs the Stomach-Qi and Lung-Qi.
Da Huang ( Rhei rhizoma), Mang Xiao ( Natrii sulfas) and Zhi Shi ( Aurantii fructus immaturus)
These herbs are cold in temperature and all enter the Large Intestine meridian. They can powerfully clear the heat there and purge the accumulation. They can be used for constipation due to excess heat in the intestines and the heat consumes the fluid there. In addition, they can reduce heat from the Lung via the approach of clearing and descending the heat in the related Fu organ, the Large Intestine. This method is often referred to as removing the fuel under a cooking pan.
Dang Shen ( Codonopsis radix) and Ren Shen ( Ginseng radix)
Dang Sheng and Ren Shen tonify the Qi and strengthen the body’s resistance. Ren Shen has a stronger function than Dang Shen. They can be used separately as assistants to tonify the Qi in the formula. The condition where excess heat consumes the Qi is manifested as tiredness, shortness of breath, constant sweating with constant high fever and a forceful pulse that is empty in the deep position.
Dan Dou Chi ( Sojae semen praeparatum)
Dan Dou Chi is pungent and slightly warm, and enters the Lung and Stomach meridians. It can disperse and spread the constrained Qi and heat in the Upper-Jiao. In the formula, it is often used as assistant with bitter and cold herbs that can descend and clear the heat. The combination of pungent and warm with bitter and cold can eliminate the heat completely.
Jin Yin Hua ( Lonicerae flos), Lian Qiao ( Forsythiae fructus) and Bo He ( Menthae herba)
These three herbs are cold in nature. They can strongly clear the heat at the Qi level and remove the heat-toxin. As they also have a dispersing tendency in action and can disperse the constrained heat and Qi, they can clear heat effectively.
Chai Hu ( Bupleuri radix) and Huang Qin ( Scutellariae radix)
Chai Hu is pungent and neutral and Huang Qin is bitter and cold. They are particularly effective in dispersing and reducing the constrained Qi and heat in the Upper-Jiao and the Gall Bladder meridian. They can treat symptoms such as fever, a bitter taste in the mouth, hypochondriac distension, poor appetite and irritability.
Jing Mi (non-glutinous rice) and Gan Cao ( Glycyrrhizae radix)
Jing Mi and Gan Cao enter the Spleen meridian and can protect the Stomach and Spleen from the cold herbs that clear heat at the Qi level. They can also tonify the Spleen-Qi and thereby strengthen body resistance. Porridge made from Jing Mi is light and easily digested. It is recommended as a food in the recovery period of a febrile disease.
Examples of classical formulas
Bai Hu Tang (White Tiger Decoction) 
Source: Shang Han Lun 
Composition
Shi Gao ( Gypsum) 30 g
Zhi Mu ( Anemarrhenae rhizoma) 9 g
Gan Cao ( Glycyrrhizae radix) 3 g
Jing Mi (non-glutinous rice) 9 g
Analysis of the formula
This formula is able to remove excess heat from the Qi level, especially from the Lung and Stomach. The manifestations are high fever without chill, perspiration, dry mouth and thirst, a red face, irritability, shortness of breath, a red tongue with a yellow coating and a rapid and forceful pulse.
In this formula:
• Shi Gao, the chief, is pungent, sweet and very cold. It enters the Lung and Stomach meridians. Shi Gao can powerfully clear the heat and reduce the fire in the Lung and Stomach. It has a pungent nature that can disperse the intensive constrained heat. At the same time, it can generate body fluids and protect the Yin of the body . It is a perfect ingredient to treat pathological change where the heat is intense at the Qi level. In a warm-febrile disease, although heat can spread to many organs, Shi Gao, as chief, clears the heat from the Stomach, the center of Yang and heat of the body, and therefore can effectively reduce heat in the entire body.
• Zhi Mu, the deputy, is bitter and cold but moist in nature. Zhi Mu enters the Lung, Stomach and Kidney meridians. It can nourish the Yin and the body fluids, clear the heat there and is used to enhance the ability of Shi Gao.
• Jing Mi and Gan Cao, the assistants, protect the Stomach and Spleen from the cold herbs. They can also tonify the Spleen-Qi to strengthen body resistance in the fight against pathogenic heat at the Qi level.
Commentary on strategies
• In this formula, Shi Gao clears heat in a direct and indirect way, demonstrating the various strategies to clear heat.
• Herbs that nourish the Yin and body fluids also play a very important role in the formula because the heat will, sooner or later, always consume the body fluids so that the heat increases quickly.
• Moreover, the formula reminds us that although body resistance is still strong at this time, one should not forget to tonify and protect the Spleen because it is the foundation of the body’s resistance.
Liang Ge San (Cool the Diaphragm Powder) 
Source: Tai Ping Hui Min He Ji Ju Fang 
Composition
Lian Qiao ( Forsythiae fructus) 1250 g
Zhi Zi ( Gardeniae fructus) 300 g
Bo He ( Menthae herba) 300 g
Huang Qin ( Scutellariae radix) 300 g
Da Huang ( Rhei rhizoma) 600 g
Mang Xiao ( Natrii sulfas) 600 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 600 g
Dan Zhu Ye ( Lophatheri herba) and honey are added in the prepared formula powder.
Analysis of the formula
This formula is able to clear heat in the Upper-Jiao, the Heart, the Lung and the diaphragm. It is used in the syndrome in which heat-toxin affects these organs and regions. The symptoms are fever, restlessness, dry mouth and throat, thirst, swollen and sore throat, ulcers in the mouth or on the tongue, red face and red eyes, scanty urine and constipation, a red border on the tongue, which is particularly dry in the middle and has a yellow coating, and a rapid and forceful pulse.
In this formula:
• The chief is Lian Qiao. It is bitter and cold but has an aromatic smell. It therefore not only clears heat but also disperses heat. Since it enters the Heart meridian, it specifically clears the excess heat in the Upper-Jiao. Lian Qiao is used in a large dosage as befits the chief in the formula.
• Four herbs form the deputy group. Huang Qin and Zhi Zi clear the heat from the Upper-Jiao. Zhi Zi and Bo He disperse the heat from the Upper-Jiao and treat restlessness, dry mouth and ulcers on the tongue. In addition, Zhi Zi and Dan Zhu Ye can clear the heat from the Heart by increasing urination.
• The assistants are Da Huang and Mang Xiao. They are used to clear heat in the intestines by purging the feces. They assist the herbs that reduce heat in the Lung via the approach of clearing and descending the heat in the related Fu organ, the Large Intestine. This method is often referred as removing the fuel under a cooking pan. In this way, they protect the body fluids from being constantly consumed.
• Zhi Gan Cao and honey serve as assistants and envoys; they can reduce the harsh action of Da Huang and Mang Xiao, and protect the Stomach.
When these herbs are used together, the heat is separated and eliminated, thus cooling down the region above the diaphragm.
Commentary on strategies
This formula demonstrates the strategies of clearing the heat. It not only reduces the heat by cooling and descending, but also by purging the bowel, increasing urination and dispersing the Qi and heat in order to separate and remove the heat. In this way the heat can be eliminated completely.
3. Syndrome of heat at the Ying level (the Nutritive level)
Manifestations
Main symptoms
Fever that worsens at night, severe irritability, restlessness, dryness in the mouth but no desire to drink.
Secondary symptoms
Delirium, vague erythema and purpura.
Tongue
Deep red without coating.
Pulse
Rapid and thready.
Associated disorders in western medicine
Severe infectious diseases.
Analysis of the syndrome
If the pathogenic heat is not eliminated at the Wei or Qi levels, it further invades the deeper level of the body, the Ying level, where the Nutritive substances of the body, such as the Yin, the blood and the essence are involved. In some severe cases, the pathogenic heat invades the Ying level directly, bypassing the first two levels.
This is the later and critical stage of a warm-febrile disease. At this stage, the pathogenic heat is strong but the body’s resistance becomes weak. The body fluids have been severely injured, and the Yin and blood are being consumed. At the same time, the heat has entered the blood and starts to disturb the blood circulation.
• Fever, which is higher in the night, is a specific sign of heat at the Ying level. Because the Yang enters the Ying level in the night, it enhances the strength of the body’s resistance so that it can pit more effort against the pathogenic heat, causing the fever to be higher in the night.
• Dryness in the mouth but with no desire to drink is another sign of heat at the Ying level as the body starts to consume the Yin instead of trying to obtain fluid by drinking.
• When the Heart-Yin and Heart-blood are injured, the Heart-shen is disturbed. Severe irritability and restlessness (even delirium) are the main symptoms of disturbance of Heart-shen.
• When heat consumes the blood and makes the blood thicker, the blood has a tendency to stagnate, manifesting as indistinct erythema and purpura.
• A deep red tongue without coating and a thready and rapid pulse are typical signs of Yin deficiency with heat.
(See Figure 3.3 on page 115.)
Treatment principle: Clear heat, cool the blood, nourish the Yin and vent heat to the Qi level
Herb selection principles and formula composition strategies
• First, herbs that are sweet, salty, bitter and cold, and can strongly reduce fire, cool the blood and nourish the Yin are selected.
• Second, herbs that reduce fire and increase body fluids are selected.
• Along with these two groups, it is equally important to select herbs that can vent the heat to the Qi level, as no matter how deeply the exterior heat has invaded the body, it must be eliminated.
CAUTIONS
1. Protect the Yin, Yang and Qi:
The bitter and cold herbs can intensively reduce heat but the bitterness possesses a drying property that may injure the Yin of the body. Bitter-cold herbs may easily injure the Stomach-Qi and Yang, as well as disturb the digestion, especially when patients have a weakness of the Spleen and Stomach.
2. Disperse and clear the constrained fire:
Herbs that are aromatic, bitter and cold, and can disperse and clear the heat should be used because they can disperse the constrained heat and may help to clear heat effectively and completely.
Structure of the formula and selection of herbs
Chief: Reduce fire, clear heat from the Heart, cool the blood and increase the body fluids and Yin
Da Qing Ye ( Isatidis folium) with Sheng Ma ( Cimicifugae rhizoma)
This combination is often used as a substitute for Xi Jiao ( Rhinoceri cornu)**, which is an important substance to reduce and disperse the heat in the blood in classical formulas. Although Shui Niu Jiao ( Bubali cornu) can substitute for Xi Jiao, it is very expensive and its smell is not pleasant.
Da Qing Ye is bitter, salty and very cold, and enters the Heart and Stomach meridians. Salt enters the blood and bitter and cold can clear heat. This herb can strongly clear the heat, remove heat-toxin and cool the blood. Sheng Ma can be used with Da Qing Ye in a ratio of 1 : 10 to disperse the heat and protect the Stomach-Qi and Spleen-Qi, which become constrained by the downward-moving herbs.
Sheng Di Huang ( Rehmanniae radix)
Sheng Di Huang is sweet and cold. It primarily enters the Heart, Stomach and Kidney meridians. It can effectively clear heat, cool the blood and nourish the Yin. It matches the syndrome perfectly and is often used as chief in formulas that clear the heat at the Ying level.
Ling Yang Jiao ( Antelopis cornu)** and Gou Teng ( Uncariae ramulus cum uncis)
Ling Yang Jiao is salty and cold, and enters the Liver, Heart and Lung meridians. It can effectively reduce the fire from the Heart and Liver, calm the mind and relax the tendons. It is often used as the chief substance in formulas that reduce the heat from the Heart and Liver when the heat disturbs the mind.
Since Ling Yang Jiao is banned, it can be replaced by Shi Jue Ming ( Haliotidis concha) and Qing Dai ( Indigo naturalis) with a small amount of Chai Hu ( Bupleuri radix).
Gou Teng is sweet and slightly cold, and enters the Liver and Pericardium meridians. It can cool the Liver, reduce the fire and relax the tendons. It is used in the condition where the Liver-heat stirs the wind so that patients suffer from dizziness, headache and irritability, and even have convulsions. As its function is not very strong, it is often used in combination with other herbs.
Dan Shen ( Salviae miltiorrhizae radix)
Dan Shen is cold and pungent, and enters the Heart meridian directly. It can cool the blood and reduce the heat in the blood. Its pungent nature disperses and dissolves the congealed blood and promotes blood circulation. It can also disperse constrained Qi in the chest. It is commonly used in combination with other chief herbs to reduce the heat at the Ying level and is a very effective herb to calm the mind and treat restlessness, irritability and a warm sensation in the chest caused by heat in the blood.
Zi Xue Dan (Purple Snow Special Pill)
This patent formula is often used to intensively reduce the excess heat and open the orifices. It is a patent formula for treating closed-up syndrome where high fever, convulsions and mental confusion exist.
Deputy: Increase the body fluids and Yin; disperse the blood stagnation
Mai Men Dong ( Ophiopogonis radix) and Xuan Shen ( Scrophulariae radix)
Mai Men Dong is sweet and cold and Xuan Shen is salty and cold. These two herbs can nourish the Yin and clear the heat. They enhance the ability of the chief ingredients to clear the heat at the Ying level.
Mu Dan Pi ( Moutan cortex)
Mu Dan Pi is bitter, pungent and slightly cold, and enters the Heart and Liver meridians. It can clear heat and cool the blood. The strong point of this herb is that it can disperse and dissolve congealed blood which is formed when the heat consumes the blood and makes it thick, and when the blood circulation is disturbed by heat.
Assistant: Clear heat; disperse and vent heat to the Qi level
Jin Yin Hua ( Lonicerae flos) and Lian Qiao ( Forsythiae fructus)
These two herbs are cold in nature and can strongly clear the heat at the Qi level. In addition, they can disperse the constrained heat and Qi, thus clearing the heat effectively. In the formula to treat heat at the Ying level they are often used as assistants to vent heat from the Ying level to the Qi level, as their aromatic smell can disperse the heat and vent the heat, eventually eliminating it from the body.
Zhu Ru ( Bambusae caulis in taeniam), Chuan Bei Mu ( Fritillariae cirrhosae bulbus) and Zhi Shi ( Aurantii fructus immaturus)
When the pathogenic heat disturbs the Qi movement and consumes the Yin, phlegm might be formed. These three herbs are able to remove phlegm and clear heat. They can be added to the formula as assistants if phlegm-heat is present.
Examples of classical formulas
Qing Ying Tang (Clear the Nutritive Level Decoction) 
Source: Wen Bing Tiao Bian 
Composition
Xi Jiao ( Rhinoceri cornu)** 2 g
Sheng Di Huang ( Rehmanniae radix) 15 g
Xuan Shen ( Scrophulariae radix) 9 g
Mai Men Dong ( Ophiopogonis radix) 9 g
Dan Shen ( Salviae miltiorrhizae radix) 6 g
Huang Lian ( Coptidis rhizoma) 5 g
Jin Yin Hua ( Lonicerae flos) 9 g
Lian Qiao ( Forsythiae fructus) 6 g
Dan Zhu Ye ( Lophatheri herba) 3 g
Analysis of the formula
This formula is devised to clear heat at the Ying level, nourish the Yin and cool the blood. The manifestations are fever that is higher in the night, irritability, restlessness and thirst with no desire to drink. In severe cases, delirium, vague erythema and purpura may appear. Patients may have a red tongue without coating or with a dry, thin coating and a rapid, forceful or thready pulse.
In this formula:
• Xi Jiao and Sheng Di Huang are used as the chief substances. They directly reduce the heat and cool the blood, as well as nourish the Yin.
• Mai Men Dong and Xuan Shen serve as deputies; they nourish the Yin and enhance the abilities of the chief ingredients.
• Five herbs serve as assistants. Dan Shen cools the blood and disperses the blood stagnation, which are the common accompanying pathological changes when there is heat at the Yin level. Dan Zhu Ye and Huang Lian can clear heat and calm the mind. Jin Yin Hua and Lian Qiao can vent the heat to the Qi level as they are aromatic herbs. They clear heat that has been vented from the Ying level in order to eliminate the heat from the body.
Commentary on strategies
This formula demonstrates the principle of treating the heat at the Ying level. Each group of herbs has specific functions:
• Herbs that clear heat and disperse heat are used together.
• Herbs that cool the blood and disperse the stagnation are used together.
• Herbs that clear heat in the Ying level and herbs that vent heat to the Qi level are used together.
Qing Gong Tang (Clearing the Palace Decoction) 
Source: Wen Bing Tiao Bian 
Composition
Xuan Shen ( Scrophulariae radix) 9 g
Lian Zi Xin ( Nelumbinis plumula) 2 g
Dan Zhu Ye ( Lophatheri herba) 6 g
Lian Qiao ( Forsythiae fructus) 6 g
Mai Men Dong ( Ophiopogonis radix) 9 g
Xi Jiao ( Rhinoceri cornu)** 2–5 g
Analysis of the formula and commentary on strategies
This formula is able to clear heat-toxin from the Heart and can nourish the Yin. It is used when the mind is disturbed by heat, and high fever, loss of consciousness and delirium are present.
• Xin means heart in Chinese. In traditional Chinese medicine, the sprout, the kernel, as the heart of a plant, is considered to enter the Heart of the human body. In this formula, this idea presents clearly.
• The first five herbs are all cold in temperature and only the sprouts of the herbs are selected as these are the coldest part of the herbs. They are used to clear heat and reduce the toxin from the Heart and nourish the Yin, hence the name of this formula – Clearing the (Emperor’s) Palace Decoction.
Ling Jiao Gou Teng Tang (Antelope Horn and Uncaria Decoction) 
Source: Tong Su Shang Han Lun 
Composition
Ling Yang Jiao ( Antelopis cornu) ** 4.5 g
Gou Teng ( Uncariae ramulus cum uncis) 9 g
Sang Ye ( Mori folium) 6 g
Ju Hua ( Chrysanthemi flos) 9 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Sheng Di Huang ( Rehmanniae radix) 15 g
Chuan Bei Mu ( Fritillariae cirrhosae bulbus) 12 g
Zhu Ru ( Bambusae caulis in taeniam) 15 g
Fu Shen ( Poriae cocos pararadicis) 9 g
Gan Cao ( Glycyrrhizae radix) 2.4 g
Analysis of the formula
This formula can cool the Liver and calm the wind, nourish the Yin and relax the tendons. It is used when heat affects the Liver and generates wind. The manifestations are high fever, restlessness and irritability, convulsions, impairment of consciousness, a deep red tongue with a dry brown coating, and a wiry and rapid pulse.
When heat is at the Ying level, the main organs involved are the Heart and the Liver. In this formula, treatment is concentrated on cooling the Liver and calming the wind.
• Ling Yang Jiao and Gou Teng are used as chief substances to directly and intensively reduce the heat and therefore extinguish wind.
• Sang Ye and Ju Hua serve as deputies to disperse the wind and heat, and cool the Liver.
• The remaining herbs serve as assistants. The combination of Bai Shao Yao, Gan Cao and Sheng Di Huang can nourish the Yin, clear heat, and ease and relax the tendons. Chuan Bei Mu and Zhu Ru eliminate the phlegm-heat that is produced by the disturbed Qi and water movement, and they may block the meridians. Fu Shen calms the mind and relaxes the tendons.
Commentary on strategies
This formula has a clear structure. The herbs that cool, pacify and soften the Liver are used together for emphasis. They bring about a quick and effective result.
4. Syndrome of heat at the Xue level (the blood level)
Manifestations
Main symptoms
Heat leads to bleeding: fever, which is higher in the night, red eyes, purpura, hematemesis, epistaxis and hemafecia.
Heat generates wind: dizziness, headache and convulsions.
Heat disturbs the mind: occasional coma, restlessness and delirium.
Tongue
Red tongue with a thin coating.
Pulse
Rapid and thready.
Associated disorders in western medicine
Severe infectious disease, primary thrombocytopenic purpura.
Analysis of the syndrome
This is the most critical stage of the warm-febrile diseases. At this stage, the Qi and Yin are seriously injured, and the heat-toxin has already entered the blood and consumed the blood. At the same time, the heat severely disturbs the blood circulation and causes bleeding.
• As soon as the blood leaves its pathway, it accumulates in one place causing blood stagnation.
• In severe cases, when the tendons lose the nourishment of the blood and Yin, the heat may generate Liver-wind, which manifests as convulsion and dizziness.
• The heat may severely disturb the Heart-shen and cause restlessness, palpitations, coma and delirium.
• The tongue and pulse signs indicate the existence of heat and a deficiency of Yin.
(See Figure 3.4 on page 116.)
Treatment principle: Clear heat-toxin, cool the blood, stop bleeding and disperse the congealed blood
Herb selection principles and formula composition strategies
• First, ingredients that are salty and cold, can cool the blood and eliminate heat-toxin should be used in large dosage.
• Second, herbs that are cold in nature, enter the blood level, can cool the blood and stop bleeding should be used in a large dosage. Along with these herbs, it is equally important to select herbs that nourish the Yin.
• Third, herbs that are pungent or having a dispersing ability and can dissolve the stagnation of the blood or prevent blood stagnation should be used.
• Herbs that can calm the mind, settle the wind and remove phlegm should be used if necessary.
CAUTIONS
1. Cool the blood and avoid blood stagnation:
To treat the syndrome of heat in the blood, an important principle is to cool the blood yet avoid blood stasis. The blood, in a normal condition, should circulate smoothly and quietly. Heat may force it to move faster and become unstable; at the same time, heat may consume the blood and cause blood stagnation and bleeding. The cold herbs may make the blood circulation slower but may also cause blood stagnation. To treat heat in the blood, herbs that enter the blood and have cold, pungent and sweet properties are more suitable for use. Their function of not only cooling the blood, but also promoting blood circulation, may prevent blood stagnation.
2. Make a clear differentiation:
Herbs that are bitter and cold in nature and enter the Qi level should not be used because the pathological change is at the blood level, not at the Qi level. Very cold herbs may cause blood stasis and bitterness may dry the blood.
Structure of the formula and selection of herbs
Chief: Reduce heat-toxin, cool the blood, open the Heart orifice and nourish the Yin
Sheng Di Huang ( Rehmanniae radix), Xi Jiao ( Rhinoceri cornu)**, Ling Yang Jiao ( Antelopis cornu)** and Gou Teng ( Uncariae ramulus cum uncis)
These substances have already been discussed in Section 3, Syndrome of heat at the Ying level. They are also used when the heat is at the Xue level under the same principle. As the condition is more severe, the dosages of these ingredients should be larger and they should be applied promptly without hesitation.
As Xi Jiao is banned, it can be replaced by Da Qing Ye ( Isatidis folium) with a small amount of Sheng Ma ( Cimicifugae rhizoma) . The banned Ling Yang Jiao can be replaced by a large amount of Shi Jue Ming ( Haliotidis concha) and Qing Dai ( Indigo naturalis) with a small amount of Chai Hu ( Bupleuri radix) .
Gou Teng is sweet and slightly cold, and enters the Liver and Pericardium meridians. It can cool the Liver, reduce the fire and relax the tendons. It is used in the condition where the Liver-heat stirs the wind so that patients suffer from dizziness, headache and irritability, and even have convulsions. As its function is not very strong, it should be used in large dosage. It is often used in combination with other herbs.
Zi Xue Dan (Purple Snow Special Pill)
This is a patent formula to intensively and quickly reduce heat-toxin and open the orifices. It is used when the heat is at the Xue level and when the mind is disturbed. Since the heat at the Xue level is dangerous and ordinary herbs are not sufficient to remove the heat-toxin quickly, this patent formula can be used promptly in acute conditions.
Bai Shao Yao ( Paeoniae radix lactiflora)
Bai Shao Yao is sour and cold, and primarily enters the Liver meridian. It can nourish the Yin and clear heat, and is used particularly to soften the Liver, nourish the tendons and relieve cramp and convulsions.
Bie Jia ( Trionycis carapax)**
Bie Jia is salty and cold, and enters the Kidney meridian. It reduces deficient heat and tonifies the Kidney-Yin. It is particularly suitable for conditions where the warm pathogenic factor has invaded the Lower-Jiao and the Qi and Yin of the body are severely impaired. These features manifest as evening fever, low-grade fever, warm palms and bone steaming.
Deputy: Cool the blood and stop bleeding; nourish the Yin, calm the mind and settle the wind
Bai Mao Gen ( Imperatae rhizoma), Ce Bai Ye ( Platycladi cacumen), Zhi Mu ( Anemarrhenae rhizoma), Qian Cao Gen ( Rubiae radix), Bai Tou Weng ( Pulsatilla radix), Huai Hua ( Sophorae flos), Di Yu ( Sanguisorbae radix) and Xiao Ji ( Cirsii herba)
These herbs are all cold in temperature and can cool the blood and stop bleeding. Bai Mao Gen and Ce Bai Ye can stop nose bleeds; Zhi Mu, Qian Cao Gen and Bai Mao Gen can treat vomiting of blood; Bai Tou Weng, Huai Hua and Di Yu are particularly effective in stopping bleeding from the intestines; Xiao Ji and Bai Mao Gen can stop bleeding from the urinary tract.
Tian Men Dong ( Asparagi radix), Mai Men Dong ( Ophiopogonis radix), Xuan Shen ( Scrophulariae radix), Hei Zhi Ma ( Sesami semen nigricum) and E Jiao ( Asini corii colla)
These herbs are able to nourish the Yin and reduce heat. Tian Meng Dong and Xuan Shen enter the Kidney meridian, particularly nourish the Kidney-Yin and reduce heat. Mai Men Dong and Xuan Shen can nourish the Heart-Yin and reduce the heat there. Hei Zhi Ma and E Jiao are moistening in nature; they nourish not only the Yin but also the essence and the blood.
Dan Shen ( Salviae miltiorrhizae radix), Huang Lian ( Coptidis rhizoma) and Zhi Zi ( Gardeniae fructus)
Dan Shen is cold and pungent, and primarily enters the Heart meridian. It can cool the blood and reduce heat in the blood. It is commonly used to reduce heat at the blood level and it particularly treats restlessness, irritability and a warm sensation in the chest. Dan Shen is also able to invigorate the blood and remove congealed blood. It is suitable for use when heat consumes the Yin and blood that leads to blood stagnation.
Huang Lian and Zhi Zi are bitter and cold. They enter the Heart and Liver meridians. They can reduce the heat from the Heart and calm the mind so that they can treat restlessness and irritability. Since bitterness has a drying nature, these herbs should be used with herbs that tonify the Yin.
Sang Ye ( Mori folium) and Ju Hua ( Chrysanthemi flos)
These two herbs are light in weight and dispersing in nature. They can spread the Liver-Qi, disperse the heat and assist herbs that calm the Liver-wind. They can treat dizziness, headache and vertigo. They are used together with herbs that calm convulsions.
Assistant: Cool the blood and promote blood circulation
Mu Dan Pi ( Moutan cortex) and Chi Shao Yao ( Paeoniae radix rubra)
Mu Dan Pi is bitter, pungent and slightly cold; Chi Shao Yao is bitter and cold. They can clear heat and cool the blood. The strong points of these herbs are that they can also dissolve congealed blood and promote blood circulation. Blood stasis often occurs when heat consumes the blood and makes blood thick. In addition, heat makes blood move erratically (‘like a river in a storm’) and also leads to blood stagnation. The cold herbs, which are used in the formula to cool the blood and stop bleeding, may also cause blood stagnation directly. Mu Dan Pi and Chi Shao Yao are particularly selected to treat these conditions.
Examples of classical formulas
Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) 
Source: Bei Ji Qian Jin Yao Fang 
Composition
Xi Jiao ( Rhinoceri cornu)** 1.5–3 g
Sheng Di Huang ( Rehmanniae radix) 30 g
Chi Shao Yao ( Paeoniae radix rubra) 12 g
Mu Dan Pi ( Moutan cortex) 9 g
Analysis of the formula
This formula is able to clear the heat from the Xue level. It removes fire-toxin, cools the blood, nourishes the Yin, dispels blood stasis and stops bleeding. It is used for fever, various types of bleeding, erythema and purpura with a deep purple color, thirst and delirium. Patients may have a deep-red tongue with a very dry coating and a rapid and thready pulse.
• Xi Jiao and Sheng Di Huang are used as chief ingredients to clear the heat in the blood directly. Xi Jiao, as well as its substitutes, is able to cool the Heart blood and reduce the fire-toxin.
• Sheng Di Huang is used in a large dosage, and is able to cool the blood and nourish the Yin.
• Mu Dan Pi and Chi Shao Yao are pungent and cold. They are able to cool the blood, reduce the heat and dissolve congealed blood. They are used as assistants in the formula.
Commentary on strategies
Although there are only four ingredients in this formula, it has a clear structure and shows the strategies of treating heat at the blood level. The four ingredients carry out the treatment procedure completely – cool the blood, stop bleeding and prevent stagnation of blood at the same time.
Qing Wen Bai Du Yin (Clear Epidemics and Overcome Toxin Decoction) 
Source: Wen Re Jing Wei 
Composition
Shi Gao ( Gypsum) 180–240 g/60–120 g/24–36 g
Zhi Mu ( Anemarrhenae rhizoma)
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Huang Lian ( Coptidis rhizoma) 12–18 g/6–12 g/3–4.5 g
Huang Qin ( Scutellariae radix)
Zhi Zi ( Gardeniae fructus)
Sheng Di Huang ( Rehmanniae radix) 18–30 g/9–15 g/6–12 g
Xi Jiao ( Rhinoceri cornu)** 18–24 g/9–15 g/6–12 g
Chi Shao Yao ( Paeoniae radix rubra)
Mu Dan Pi ( Moutan cortex)
Dan Zhu Ye ( Lophatheri herba)
Lian Qiao ( Forsythiae fructus)
Xuan Shen ( Scrophulariae radix)
Jie Geng ( Platycodi radix)
The dosages of some herbs are not recorded in the original book.
Analysis of the formula
This formula is able to clear heat at the Qi, Ying and Xue levels together. It can relieve toxicity, cool the blood and drain fire. It is used in pestilence, a kind of virulent infectious disease that is caused by heat-toxins, such as epidemic cerebrospinal meningitis, poliomyelitis and SARS. The syndrome manifests as high fever, intense thirst, severe stabbing headache with nausea, extreme irritability and insomnia. In severe cases, there may be delirious speech, convulsions, erythema and purpura with a deep purple color, vomiting of blood and nose bleeds. The patient may have a deep-red tongue with a dry yellow coating, and a rapid and deep, or rapid, deep and thready pulse.
In this formula:
• Shi Gao, Zhi Mu and Zhi Gan Cao, the main part of Bai Hu Tang (White Tiger Decoction), are used to clear the heat at the Qi level.
• Xi Jiao, Sheng Di Huang, Mu Dan Pi and Chi Shao Yao, the ingredients of Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction), are used to cool the blood and remove heat-toxin from the blood. Together they are considered to be the chief part of the formula.
• Huang Lian, Huang Qin and Zhi Zi are selected from the formula Huang Lian Jie Du Tang (Coptis Decoction to Relieve Toxicity), which can directly drain fire and fire-toxin. Together they are considered to be the deputy part of the formula.
• Xuan Shen can nourish the Yin, drain the fire, cool the blood and reduce heat-toxin. It also serves as a deputy, in particular to enhance the ability of Sheng Di Huang.
• Dan Zhu Ye and Lian Qiao are assistants. They can clear the heat from the Qi level, and therefore can vent the heat from the Ying level to the Qi level.
• Jie Geng is used as envoy. It has an ascending ability, and can disperse the Lung-Qi and convey the rest of the herbs in the formula to the Lung for further spread in the body.
Commentary on strategies
Although this formula is large in size, it is clear in structure and strong in function.
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