Chapter Ten. Syndrome of Qi stagnation and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of the formulas that regulate, smooth or spread the Qi. They are used to treat the syndrome of Qi stagnation.
The characteristic of the syndrome of Qi stagnation is distension in the affected region. The quality of distension is determined by the degree of stagnation; generally speaking, fullness exists in a mild case, distension is seen in an advanced case and pain occurs in a severe condition.
The syndrome of Qi stagnation varies according to the affected organs and regions:
• If the Lung-Qi stagnates, the symptoms are breathlessness, stifling in the chest, cough and wheezing.
• If the Stomach-Qi and Spleen-Qi stagnate, the manifestations are fullness and distension of the entire abdomen, reduced appetite, belching, nausea, vomiting, abdominal pain and irregular bowel movement.
• If the Liver-Qi stagnates, the symptoms are hypochondriac distension and pain, pain in the lower abdomen and the lateral sides of the abdomen, irritability, depression, distension and pain in the breasts, and irregular menstruation.
• If the Qi stagnates in the meridians, the main symptoms are stiffness, heaviness, numbness or tingling of the limbs in the affected regions, or migrating pain in the limbs.
Stagnation of Qi is often caused by emotional disturbance and accumulation of internal cold, heat, phlegm, water and food. It also occurs in trauma and stagnation of blood.
The compositions of the formulas that regulate the Qi have the following characteristics:
1. Herbs with a pungent and warm nature are selected because pungency possesses a moving capacity and warmth may activate the Qi movement.
2. Herbs that enter the Liver, Spleen, Stomach, Large Intestine and Lung meridians are often used because these organs directly influence the Qi movement of the body.
3. Herbs that remove different obstructions in order to promote the Qi movement are used, such as herbs that eliminate phlegm, remove food stagnation, promote bowel movement, transform dampness, warm the interior, clear heat and release the exterior.
Although Qi moves in every organ of the body, the Liver, Spleen, Stomach, Large Intestine and Lung directly influence Qi movement. As the syndromes of Qi stagnation are more often seen in these organs, in this chapter the syndromes and compositions of formulas are introduced particularly for these organs.
CAUTIONS
1. Caution during pregnancy, heavy menstruation or in bleeding conditions:
Since the formulas can activate the blood circulation as well as the Qi movement, they can make the bleeding heavier or may cause miscarriage in early pregnancy.
2. Caution in conditions of Yin deficiency:
Formulas that regulate Qi contain many pungent and warm herbs and they easily injure the Yin and body fluids. Patients with Yin deficiency should not use these formulas in large dosage or for a very long period of time.
1. Syndrome of Liver-Qi stagnation
Manifestations
Main symptoms
Distension (even pain) in hypochondria and lateral sides of the lower abdomen, stiffness of the muscles and tendons, especially of the neck, shoulders and back, irregular menstruation, easily irritated, restlessness, dream-disturbed sleep and depression.
Secondary symptoms
Fullness in the chest, hoarseness, cough, distension in the stomach, obviously reduced or increased appetite, belching, nausea, vomiting, difficult urination, difficult bowel movement or diarrhea, dysmenorrhea, irregular menstruation.
Tongue
Normal, slightly pale, red or purple, with a white coating or a sticky coating if accompanied by accumulation of dampness, food or phlegm.
Pulse
Wiry, or wiry and thready if accompanied by blood or Yin deficiency.
Associated disorders in western medicine
Dysmenorrhea, irregular menstruation, premenstrual syndrome and menopause syndrome, hepatitis, peptic ulcer, duodenal ulcer, irritable bowel syndrome, colitis, cholecystitis and depression.
Analysis of the syndrome
The Liver is considered to be a very important organ for Qi movement throughout the entire body. The Liver-Qi moves freely through the San Jiao passage, promotes the Qi movement of all the other organs and accelerates their physiological functions. Pathologically, movement of the Liver-Qi can be disturbed by different factors, such as emotional disturbance, especially stress, anger and frustration, which can directly cause the stagnation.
• When the Liver-Qi is stagnant, patients usually lose their amiable manner and show symptoms such as irritability, quick temper, high tension of muscles and depression. In addition, distension and pain often occur in the hypochondriac region and lateral sides of the lower abdomen.
• Since the Liver houses the Hun (soul), patients may suffer from insomnia and dream-disturbed sleep when the Liver-Qi is stagnant.
• When the Liver-Qi and Liver-blood both stagnate, dysmenorrhea or irregular menstruation may appear.
• Stagnation of the Liver-Qi shows in a normal or slightly pale tongue with a white coating and a wiry pulse.
Once the Liver-Qi stagnates, it easily overacts or insults the other organs.
• When the Liver-Qi attacks the Spleen and Stomach, fullness, distension of the abdomen and obviously reduced or increased appetite may occur. In a severe condition where the Stomach-Qi cannot descend, belching, nausea and vomiting may present. When the Spleen-Qi fails to ascend, difficult bowel movement or diarrhea may occur.
• If the Liver-Qi attacks the Lung, shortness of breath, hoarseness and cough may start.
• When the Liver-Qi blocks the San Jiao passage, there may be difficult urination.
• If the Liver-Qi affects the Heart, restlessness and insomnia take place.
(See Figure 10.1 on page 269.)
Treatment principle: Regulate Liver-Qi; nourish Liver-Yin and Liver-blood; harmonize Qi movement of other involved organs
Herb selection principles and formula composition strategies
• First, herbs that are pungent and warm, enter the Liver meridian and can spread the Liver-Qi are selected.
• Second, herbs that promote the Qi movement or promote the functions of the Gall Bladder, Spleen, Stomach and Large Intestine are selected.
• Third, herbs that remove accumulation of food, dampness and phlegm are selected.
• It is also necessary to select herbs that enter the Liver, Heart and Lung meridians, and can improve sleep and calm the mind if depression and frustration are present.
• If the Liver-Qi is disturbed by Liver-fire, or uprising of Liver-Yang or Liver-wind, it is important to select herbs that can treat these disorders, thereby allowing the Qi to move smoothly.
• Herbs that tonify the Spleen-Qi and nourish the Liver-blood and Liver-Yin are selected when deficiency of these organs leads to stagnation of the Liver-Qi.
Structure of the formula and selection of herbs
Chief: Spread the Liver-Qi
Xiang Fu ( Cyperi rhizoma) and Chai Hu ( Bupleuri radix)
Xiang Fu is a very commonly used herb to regulate the Liver-Qi. It is pungent, sweet, slightly bitter and warm, and enters the Liver and San Jiao meridians. Xiang Fu is an effective and gentle herb to regulate Qi. It is warm and pungent without a harsh and drying nature. It promotes the Liver-Qi movement without the side effect of injuring the Yin and blood of the Liver. As it is somewhat bitter, it can reduce the slight Liver-heat that is generated by the Liver-Qi stagnation. The sweetness can soften the Liver and moderate the speed of the Qi movement. All these characteristics match the pathological changes in the syndrome of Liver-Qi stagnation. Because it enters the San Jiao meridian that is the passage of the Qi and water, it can effectively spread the Qi in the entire body.
Since Xiang Fu is gentle and effective in regulating the Liver-Qi, it is often selected in formulas for treating both excess and deficiency syndromes that are associated with Liver-Qi stagnation.
Chai Hu is another commonly used herb to regulate the Liver-Qi, and it is a gentle herb too. Unlike Xiang Fu, it is pungent and neutral. It has the function of dispersing and ascending the Liver-Qi rather than promoting the circulation of the Liver-Qi. It is particularly suitable for use as chief in formulas to treat constraint of the Liver-Qi, such as in stress, depression with anger and frustration, and chronic Liver and Gall Bladder diseases. Since it has an upward-moving tendency, it should be used with caution when treating syndromes where Qi, fire or Yang of the Liver move upwards, as it can easily cause headache or dizziness.
Qing Pi ( Citri reticulatae viride pericarpium), Chuan Lian Zi ( Toosendan fructus) and Wu Yao ( Linderae radix)
Qing Pi is the peel of unripe tangerines. It is warm and bitter, and enters the Liver, Gall Bladder and Spleen meridians. It can break up Qi stagnation and is effective in promoting the free flow of Liver-Qi and alleviating pain. It is often selected in a formula to treat distending pain in the chest, breasts and hypochondriac region. It can also dissolve phlegm accumulation. Because its action is strong, it may injure the Qi and Yin. Therefore this herb is only used for a short period of time and in excess conditions.
Chuan Lian Zi is very bitter and cold. It can intensively drain the Liver-fire and direct the Liver-Qi downwards. It is selected in formulas for treating syndromes where Liver-fire flares up and Liver-Qi movement is disturbed. The disorder is manifested as irritability, distension in the hypochondria, insomnia, quick temper, red eyes, headache, red tongue with a yellow coating and a forceful, wiry and rapid pulse. Because Chuan Lian Zi is very bitter and cold, it easily injures the Stomach. This herb should not be used for a long period of time or in large dosage, because it is a toxic herb. Overdose may cause nausea, vomiting, diarrhea, dyspnea and arrhythmia.
Wu Yao is pungent and warm, and enters the Lung, Spleen, Kidney and Bladder meridians. Wu Yao can warm these organs and expel the cold, regulate the Qi and release the pain. Since the Liver meridian passes the external genital region, Wu Yao can also regulate the Liver-Qi. It is particularly effective in relieving pain in the lateral sides of the lower abdomen and the genital area, and treats dysmenorrhea, hernia inguinalis, frequent urination and urinary incontinence due to cold in the Liver and Kidney meridians and stagnation of the Liver-Qi.
Bai Shao Yao ( Paeoniae radix lactiflora)
Since the Liver stores blood, which is the basis of free flow of the Liver-Qi, deficiency of blood can cause stagnation of Liver-Qi. However, as stimulating the Qi in treatment may injure the blood and cause further stagnation of the Qi, it is necessary to nourish the blood in order to spread the Liver-Qi.
Bai Shao Yao is the most commonly used herb to soften the Liver. It is sour, bitter and slightly cold. It is able to nourish the Yin and blood of the Liver, and its cold and bitter nature can reduce heat, which is caused by deficiency of blood and stagnation of the Liver-Qi. It is often used in a formula to treat Liver-Qi stagnation, which is caused by Yin and blood deficiency. As well as the common symptoms of Qi stagnation, a thready and wiry pulse is often an indication for using this herb in the formula.
Deputy: Regulate the Qi movement and blood circulation in related organs
Chen Pi ( Citri reticulatae pericarpium), Zhi Ke ( Aurantii fructus) and Zhi Shi ( Aurantii fructus immaturus)
These herbs are selected to regulate the Qi. Chen Pi is dried tangerine peel. It is pungent, bitter and warm, and enters the Stomach and Spleen meridians. It is effective for regulating the Qi of these organs. In the formula for promoting Liver-Qi movement, it is often selected to enhance the chief by moving the Qi and eliminating the dampness and phlegm from the Middle-Jiao. Its aromatic smell can stimulate the Spleen, transform the dampness and soothe the Stomach-Qi. Chen Pi is often used for distension and pain in the abdomen, reduced appetite, fullness of the stomach, nausea and vomiting.
Zhi Ke has a similar function to Chen Pi but it is cold in nature and its function of regulating the Qi is gentler and slower. It moves horizontally in the Upper- and Middle-Jiao. In a formula that treats Liver-Qi stagnation with slight Liver-heat, Zhi Ke is very often used to open up the Qi obstruction in the chest, stomach and hypochondria to reduce fullness and distension.
Xiang Yuan ( Citri fructus), Fo Shou ( Citri sarcodactylis fructus) and Zi Su Geng ( Perillae caulis et flos)
These herbs are used when Liver-Qi attacks the Stomach. Xiang Yuan and Fo Shou are bitter, sour and slightly warm, and enter the Liver, Spleen and Stomach meridians. Both are very effective in promoting Liver-Qi movement and treating hypochondriac pain, distension and depression. Moreover, they are particularly effective in treating a condition where stagnant Liver-Qi disturbs the Stomach and leads to stifling in the chest and distension in the gastric and hypochondriac regions. They can soothe the Stomach-Qi, thereby improving appetite and stopping vomiting and belching.
Zi Su Geng is slightly pungent and warm, and enters the Lung and Spleen meridians. This herb has a similar function to Xiang Yan and Fo Shou, but it is gentler. It is particularly suitable for a weak person who suffers from Liver-Qi stagnation and Stomach-Qi disturbance. It can also calm the fetus and is useful for pregnant women who suffer from disharmony between the Liver and the Stomach.
Ju Luo ( Citri reticulatae fructus retinervus), Si Gua Luo ( Luffae fructus), Ju Ye ( Citri reticulatae folium) and Ju He ( Aurantii semen)
These herbs are used to dissipate nodules. Ju Luo is sweet, bitter and neutral, and enters the Liver and Lung meridians. According to the concept that the pith of fruit enters the collaterals of the human body, Ju Luo is able to regulate the Qi, open up the collaterals and remove phlegm there. It can be used with other herbs such as Si Gua Luo and Ju Ye to regulate the Liver-Qi in order to treat distending pain in the breasts and hypochondria, such as in premenstrual syndrome and mastopathy.
Ju Ye is pungent, bitter and neutral. Like Ju Luo, it enters the Liver meridian, particularly regulates the Liver-Qi and dissipates nodules. Its action is stronger than that of Ju Luo. It also enters the Stomach meridian and regulates the Stomach-Qi. Because the Liver and Stomach meridians pass the breasts, this herb is able to treat distending pain of the breasts.
Ju He is pungent, bitter and neutral, and enters the Liver and Kidney meridians. It is effective for regulating Qi, dissipating nodules and stopping pain. According to the concept that seeds move downwards, it is especially applied to treat cold accumulation in the Liver meridian that is manifested as cramping pain on the lateral sides of the lower abdomen with a cold sensation, such as in dysmenorrhea, amenorrhea, inguinal hernia and hydrocele of the testis.
Mu Xiang ( Aucklandiae radix)**
Mu Xiang is pungent, bitter, warm and aromatic, and enters the Gall Bladder, Spleen and Large Intestine meridians. It can strongly and quickly activate the Qi movement; it especially regulates Qi in the intestines and alleviates pain. It also strengthens the Spleen and promotes digestion. It is particularly effective in treating disorders where Liver-Qi overacts on the Spleen, causing stomachache, abdominal pain and distension, diarrhea, poor appetite and poor digestion, such as in colitis, peptic ulcer, hepatitis and irritable bowel syndrome. Since this herb is quite warm and pungent, and is strong in action, its dosage should be controlled carefully.
Mei Gui Hua ( Rosae flos), Chuan Xiong ( Chuanxiong rhizoma), Yu Jin ( Curcumae radix) and Yan Hu Suo ( Corydalidis rhizoma)
These herbs are selected to promote blood circulation. Mei Gui Hua has the function of harmonizing the Qi of the Liver and Stomach, and treating the syndrome of Liver-Qi attacking the Spleen and Stomach. Its function is quite similar to that of Xiang Yuan ( Citri fructus) and Fo Shou ( Citri sarcodactylis fructus). However, this herb can promote both Qi and blood circulation and is an appropriate herb to treat disorders due to both Qi and blood stagnation, such as in irregular menstruation and dysmenorrhea.
Chuan Xiong, Yu Jin and Yan Hu Suo are herbs that promote blood circulation. As they are able to move the Qi in the blood, they are considered as the Qi-moving herbs in the blood. In formulas that regulate the Liver-Qi, they may be selected in conditions of Qi and blood stagnation, or for the purpose of activating the blood in order to accelerate the Qi movement. As Chuan Xiong and Yan Hu Suo are warm in temperature and Yu Jin is cold, they should be selected according to the nature of the syndrome.
Gan Cao ( Glycyrrhizae radix) Mu Gua ( Chaenomelis fructus), and Bai Shao Yao
These herbs are selected to relax tendons. Gan Cao is sweet in nature and enters all meridians. It is often used together with sour herbs such as Bai Shao Yao ( Paeoniae radix lactiflora) and Mu Gua to generate Yin to soften the Liver, ease the muscles and tendons, relieve cramp and reduce high tension in the body.
Mu Gua is sour and warm, and can relieve cramp of the muscles. Its function is quite different from that of Bai Shao Yao, which is able to soften the Liver, nourish the Yin and ease the muscles. Mu Gua is able to remove dampness from the meridians, thus treating cramp of the muscles and tendons.
Assistant: Tonify the blood and Qi; reduce the excess in order to harmonize the Liver-Qi
Bai Shao Yao ( Paeoniae radix lactiflora) and Dang Gui ( Angelicae sinensis radix)
They are the most commonly used pair of herbs in a formula that treats Liver-Qi stagnation caused by blood deficiency. A thready and wiry pulse is an important sign of blood deficiency with stagnation of the Liver-Qi. Dang Gui is pungent, sweet and slightly warm; Bai Shao Yao is sour, bitter and slightly cold. When Dang Gui and Bai Shao Yao are used together, they can harmonize the blood circulation properly: the first is warm, and it can disperse and promote the blood circulation; the second is cold, and it can moderate and stabilize the blood circulation. Although both can tonify the blood, Dang Gui is focused on the promoting function of the blood while Bai Shao Yao is focused on nourishing the substantial part of the blood.
Dang Shen ( Codonopsis radix) and Bai Zhu ( Atractylodis macrocephalae rhizoma)
Dang Shen and Bai Zhu are able to tonify the Qi and strengthen the function of the Spleen. They are often used as assistants in a formula that treats Liver-Qi stagnation with Spleen-Qi deficiency. Another reason to use herbs which tonify the Spleen is that, as in a chronic condition of Liver-Qi stagnation, the Liver is almost always overacting on the Spleen. It is wise therefore to tonify the Spleen before it is badly weakened.
Bai He ( Lilii bulbus) and Suan Zao Ren ( Ziziphi spinosae semen)
These herbs can be used as assistants in formulas that spread the Liver-Qi when the Qi disturbs the mind and influences sleep. Bai He is sweet and slightly cold, and enters the Lung and Heart meridians. It can calm the mind and treat depression, anxiety and insomnia. Suan Zao Ren is able to nourish the blood of the Liver and improve sleep.
Zhi Zi ( Gardeniae fructus), Shi Jue Ming ( Haliotidis concha), Gou Teng ( Uncariae ramulus cum uncis) and Ju Hua ( Chrysanthemi flos)
Zhi Zi is bitter and cold, and enters the San Jiao meridian. It can clear the heat and reduce the excess fire from the Heart, Liver and Bladder by increasing urination. In formulas that regulate Liver-Qi, this herb can be used in cases of Liver-heat or Liver-fire presentation. A red tongue with a yellow coating and a wiry pulse suggest the existence of this disorder.
Shi Jue Ming is a mineral substance that can descend the Liver-Yang. It is used in a formula when the Liver-Yang ascends. Common symptoms are dizziness, dry eyes and blurred vision, and a wiry or tight pulse.
Gou Teng can cool the Liver and relieve convulsions. Ju Hua can disperse Liver-heat. Both can be applied in either an excess or a deficiency condition of Liver-heat syndrome.
Jiang Can ( Bombyx batrycatus), Di Long ( Pheretima) and Chan Tui ( Cicadae periostracum)
These substances particularly open up the meridians and collaterals, and treat numbness of the limbs caused by Liver-wind. Jiang Can and Chuan Tui are also used for itchy skin disorders caused by Liver-wind and Liver-heat.
Envoy: Harmonize the herbs in the formula
Zhi Gan Cao ( Glycyrrhizae radix preparata)
Zhi Gan Cao is sweet in nature and is used as envoy to harmonize the herbs that regulate the Qi by moving in different directions in the body.
Common accompanying symptoms and treatment
• Fullness in the stomach and reduced appetite due to Liver-Qi attacking the Spleen: use Bai Zhu ( Atractylodis macrocephalae rhizoma) and Fu Ling ( Poria) to strengthen the Spleen; use Hou Po ( Magnoliae cortex), Sha Ren ( Amomi xanthioidis fructus) and Mu Xiang ( Aucklandiae radix)** to regulate the Qi in the Spleen and Large Intestine; use Fang Feng ( Saposhnikoviae radix) to expel wind caused by tension in the Large Intestine; use Xiang Yuan ( Citri fructus) and Fo Shou ( Citri sarcodactylis fructus) to harmonize the Liver and Stomach.
• Nausea and belching due to Liver-Qi attacking the Stomach: use Zi Su Ye ( Perillae folium), Ban Xia ( Pinelliae rhizoma), Huang Qin ( Scutellariae radix) and Pi Pa Ye ( Eriobotryae folium) to soothe the Stomach-Qi.
• Distending pain of abdomen and irregular bowel movement due to Liver-Qi disturbing the function of the Large Intestine: add Mu Xiang ( Aucklandiae radix)** and Bing Lang ( Arecae semen) to regulate the Qi in the Liver and Large Intestine.
• Fullness in the chest, difficult urination and edema due to Liver-Qi blocking the San Jiao water passage: add Sang Bai Pi ( Mori cortex), Su Geng ( Perillae caulis) and Xing Ren ( Armeniacae semen) to descend and regulate the Qi in the Lung.
• Jaundice, reduced appetite, hypochondriac pain and fullness due to Liver-Qi disturbing the Gall Bladder: use Yin Chen Hao ( Artemisiae scopariae herba), Zhu Ru ( Bambusae caulis in taeniam) use Yu Jin ( Curcumae radix) to regulate the Qi and remove the damp-heat from the Gall Bladder.
• Distending pain in the breasts, especially before menstruation, due to Liver-Qi obstructing the collaterals: use Ju Luo ( Citri reticulatae fructus retinervus) and Si Gua Luo ( Luffae fructus) to open up the collaterals.
Examples of classical formulas
Si Ni San (Frigid Extremities Powder) 
Source: Shang Han Lun 
Composition
Chai Hu ( Bupleuri radix) 6 g
Zhi Shi ( Aurantii fructus immaturus) 6 g
Bai Shao Yao ( Paeoniae radix lactiflora) 9 g
Zhi Gan Cao ( Glycyrrhizae radix preparata) 6 g
Analysis of the formula
This formula is able to free the constrained Liver-Qi and regulate the Spleen. It is a formula devised for stagnation of Liver-Qi, which may happen in a stressful situation. When Qi stagnates, the patient has fullness in the chest and distension of the hypochondria and abdomen. When Qi is not able to reach the extremities, the patient has cold fingers. If the Liver overacts on the Spleen, abdominal pain may also present. The patient may have a wiry pulse.
In this formula:
• Chai Hu is used as chief. It directly disperses the Qi and releases the constraint of the Qi in the Liver, Gall Bladder and San Jiao.
• Zhi Gan Cao is used as deputy to strengthen the Spleen and protect the Middle-Jiao. It is particularly useful when the Liver overacts on the Spleen.
• The sour Bai Shao Yao and sweet Zhi Gan Cao are used together as deputies to generate the Yin. They can soften the Liver, ease the muscles and release the cramp and stiffness so as to help Chai Hu spread the Liver-Qi.
• Zhi Shi is used as assistant to descend the Qi to help the chief regulate the Qi efficiently. It can also regulate the Qi in the intestines, and reduce distension and pain.
• Zhi Gan Cao is also used as envoy in the formula to harmonize the herbs that work on different aspects in the syndrome.
Commentary on strategies
Although there are only four herbs in this formula, it shows several treatment strategies to spread the Liver-Qi.
• First, Chai Hu is used to free the constrained Qi instead of using Xiang Fu ( Cyperi rhizoma), the most commonly used herb to regulate the Liver-Qi. Because Chai Hu moves upwards and outwards, it is more suitable in situations of Qi constraint.
• Second, the combination of ascending and descending herbs can activate the Qi movement more effectively than using herbs that move in only one direction.
• Third, herbs that soften the Liver are used to help spread the Qi smoothly.
• Fourth, herbs that harmonize the Liver and Spleen are used at the same time.
Chai Hu Shu Gan San (Bupleurum Powder to Spread the Liver) 
Source: Jing Yue Quan Shu 
Composition
Chai Hu ( Bupleuri radix) 6 g
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