01August

Gan Zhou - Liver Fixity, Jin Gui Yao Lue, Chapter 11, Item 7

by Alex Tiberi, Lic. Ac.

Summary

This paper examines the disorder of Gan Zhou or Liver Fixity as presented in Chapter 11 Item 7 in the Jin Gui Yao Lue. As presented in the Jin Gui, liver fixity is an aspect of binding qi depression of the liver also know as liver qi stagnation with blood stasis in the luo vessels of the chest, which may also be affecting the function of the lungs and stomach. It has modern application in many disorders such as chronic hepatitis, liver cirrhosis, cardiac ischemia, and chronic gastritis. This paper presents the pathomechanism for liver fixity as well as suggesting herb formulas and modifications for its’ treatment.

Summary

This paper examines the disorder of Gan Zhou or Liver Fixity as presented in Chapter 11 Item 7 in the Jin Gui Yao Lue. As presented in the Jin Gui, liver fixity is an aspect of binding qi depression of the liver also know as liver qi stagnation with blood stasis in the luo vessels of the chest, which may also be affecting the function of the lungs and stomach. It has modern application in many disorders such as chronic hepatitis, liver cirrhosis, cardiac ischemia, and chronic gastritis. This paper presents the pathomechanism for liver fixity as well as suggesting herb formulas and modifications for its’ treatment.

Gan Zhuo 肝著 Liver Fixity

Jin Gui Yao Lue, Chapter 11 Line 7 states:

“With Gan Zhou (hereafter translated as Liver Fixity), the patient often desires trampling on the chest. Before the acute stage (or alternatively when the symptoms are not present), he only desires hot drinks. Xuan Fu Hua Tang (Inula Flower Decoction) is indicated.”

With these three short sentences many questions are engendered:

• What exactly is Liver Fixity?
• What is its’ pathomechanism?
• Is it the same as Gan Zhang, Liver distension?
• Why is Xuan Fu Hua Tang prescribed?
• Could there be an error in the text?
• In fact, is it even a disorder of the liver at all?
• What other formulas can be used?
• What is its’ application in today’s clinical practice?

Definition

The definition of Liver Fixity from the New Century Chinese-English Dictionary of Traditional Chinese Medicine, published by the People’s Military Medical Press in 2004 states: Liver Fixity (Gan Zhou Bing) is a disease of liver obstruction. It refers to meridian obstruction of the flow of qi and blood due to dysfunction of the liver in maintaining the free flow of qi caused by pathogens. Its’ manifestations are fullness of the chest and hypochondrium, or possibly distending or pricking pain, which may get better by kneading or pressing.

The first symptom given in the Jin Gui is “the patient often desires trampling on his chest. Here we notice a discrepancy in the Jin Gui description and the dictionary definition. The Jin Gui says the patient desires trampling on the chest; the definition says the pain may get better by kneading or pressing. Many commentators interpret trampling was a specific massage technique and was indicated for various kinds of obstructions and accumulations.

The text Chinese Massage Therapy, published by Shandong Science and Technology Press, 1989 says it is a particularly strong technique but is very useful in blockage symptoms due to wind, cold, or damp. A particularly interesting reference can be found in the 52 Prescriptions section of the Mawangdui medical manuscripts. For phlegm nodules in the inguinal area, trampling should be applied, preferably by someone who has had their feet amputated, and thus is wearing soft flat leather shoes. (I haven’t had the opportunity to test this clinically.) While light massage can invigorate stagnation, heavy massage is uncomfortable in excess conditions. So the fact that trampling is indicated could be an indication to look for a deficiency underlying the stagnation.

The second symptom is “before the acute stage he, the patient, only desires hot drinks”. This preference for hot drinks appearing before the other symptoms is typically said to indicate one of three possibilities: the first is that the causative invading pathogenic factor is cold, the second is that the yang qi is affected but the stagnation has not yet occurred, thus the hot water assists the yang qi in dispersing the cold, and the third is that the hot water benefits the spleen and enables it to transform the accumulating glomus. (That is, the patient may be thirsty because the water metabolism is affected and fluids are not circulating giving accumulation of damp in one area and dryness in another. (This view in particular is emphasized by those who feel liver fixity is, in reality, a lung and spleen disorder rather than a liver disorder.)

The distinction between the first two interpretations (invasion by cold pathogens and inhibition of yang qi) is important because those commentators who emphasize the inhibition of yang qi say the problem is still at the qi level but that the stagnation has not yet affected the blood. Those commentators who say the craving of warm drinks is a direct response to the cold pathogen expound the view that liver fixity is a unique type of liver blood stasis where the blood stasis occurs in the small collaterals first, and only then does the qi get blocked. Those commentators support this view through the statement in the item in the Jin Gui: “Xuan Fu Hua Tang is indicated.” The argument advanced is that if qi stagnation was the primary aspect, formulas containing liver qi regulating herbs and thus more directly targeting liver qi stagnation would be first indicated.

This brings us to an important aspect of interpretation of the Shang Han Lun and Jin Gui Yao Lue, that in order to understand an item we must often carefully examine the governing formula indicated in the item. In general the steps for understanding a condition presented in the Shang Ha Lun or Jin Gui are as follows:

• Examine the symptoms and signs listed
• Examine the nature of the formula that governs the condition
• Put the item in context by looking at the related items in the text,
• Examine other classical sources that discuss the condition
• Look at clinical applications both historical and modern.

So let’s examine Xuan Fu Hua Tang. Xuan Fu Hua Tang Ingredients:

• Xuan Fu Hua (Inula Flos) 9 grams
• Cong Bai (Allii fistulosi Bulbos) 14 stalks
• Xin Jiang (New Crimson) Small Amount

The first ingredient, Xuan Fu Hua, is listed in the Shen Nong Ben Cao in the herbs of the middle class. It is salty and warm, treats bound qi, rib-side fullness, fright palpitations, removes water, eliminates cold and heat in the fiver viscera,, supplements the center, and downbears the qi. This last indication is especially of note.

There is a traditional saying, “All the hundreds of flowers upbear except for Xuan Fu Hua which downbears.” As one aspect of the pathomechanism of Liver Fixity is upsurging of Liver qi due to cold, this downbearing function is particular note. Because of the combination of its’ downbearing nature and its’ ability to remove water, Xuan Fu Hua can treat phlegm glomus, water swelling, head wind, and belching. Later ben cao add that Xuan Fu Hua enters the Liver, Lung, Stomach, and Spleen meridians; that it is more bitter in taste with the plants leaves being more salty; and that its’ primary indications are congested fluid disorders with wheezing, coughing, and copious phlegm; and to stop vomiting and hiccups due to cold deficiency and/or dampness of the stomach and spleen.

The second ingredient, Cong Bai, is not listed in the Shen Nong Ben Cao. Only its’ seed, Cong Shi, is mentioned. However, Tao Hong-jing gave a comment as to the function of Cong Bai: “It mainly treats bone and flesh pain in cold damage, and throat impediment with block. It quiets the fetus, brightens the eves, eliminates evil qi in the liver, quiets the center, disinhibits the five viscera, boosts the eye essence, and resolves the toxins of the hundreds of medicinals.” Later ben cao add that Cong Bai is acrid and warm, and enters the Lung and Stomach meridians. Its’ main functions are releasing the exterior in external wind cold, disperse cold and unblock the yang qi, thus helping either abdominal pain and distension or nasal congestion from yang qi blocked by cold, and relieving toxicity and dispersing clumps.

The third ingredient, Xin Jiang, engenders some disagreement in identification. The most common modern interpretation follows the commentary of Tao Hong-jing, and identifies Xin Jiang with Qian Cao Gen, Rubiae Radix, and it is included at a dosage between 6-9 grams. In fact, Xin Jiang is new red dyed cloth, whose dye was indeed composed of Qian Cao Gen, but also contained Su Mu, Sappan Lignum, and Hong Hua, Carthami Flos, or more often, Xi Hong Hua, Tibetan Saffron. Furthermore, the Qian Cao Gen was processed in the making of dye with vinegar and alcohol to make the color stronger. Modern studies indicate this may increase the potency of the dye up to 40%. Thus Xin Jiang traditionally prepared would have a relatively strong blood moving effect.

Ye Tian-shi was of the opinion that Xin Jiang had the function of both moving blood and regulating qi and helped reestablish the qi mechanism throughout the body. He standardly included herbs such as Dang Gui, Angelica Sinensis, Dan Shen, Salviae Miltiorrhizae, and Tao Ren, Persica Semen, to reinforce these effects. [As an aside, this dye was known in very ancient times, having been found at an archaeological site in India dating to 3000 BCE. It was used by hermits to dye their clothes and is the dye used by Buddhist monks to obtain their “saffron robes.]

It is of particular interest to Americans as it was the dye used by the British to make their army’s infamous “redcoats” during the American Revolutionary War (1775-1783). A British herbal text of that period says that it could be used for swelling of the spleen, to bring on late menstruation, and may be used topically to remove discolorations of the skin.] Later ben cao follow the characteristics of Qian Cao Gen and say that Xin Jiang enters the Liver and Heart meridians and is bitter and cold. It cools the blood and stops bleeding, and invigorates the blood and dispels blood stasis to eliminate pain especially in the chest and flanks, as well as in the joints.

 

Herb Interactions

To analyze the interaction of the herbs in the formula: Xuan Fu Hua is the Emperor. It downbears the upsurging liver, while simultaneously boosting the lung. It also drains water qi under the ribs, which may be accumulating due to the lack of qi movement. Cong Bai is the Minister. Its’ direction is upward, and it frees the blocked yang qi which is causing discomfort in the chest. Thus, these two herbs together form a downward and upward moving partnership that serves to reestablish the qi mechanism of the body. Thus the liver is benefited in spreading qi, the lung is strengthened, the stomach is warmed, and the spleen is dried of dampness.

Xin Jiang is the Assistant (and Messenger). It moves the stagnation of blood in the small vessels allowing for more free movement of qi and enabling the liver to spread qi more effectively. (In fact, according to some commentators, the very origin of this problem begins with blood stagnation in the small vessels, so this herb while only an assistant, is actually targeting the root cause.) When this formula is used in uterine bleeding during pregnancy, the hemostatic action of this herb becomes important. This formula follow a typical characteristic of formulas from the Shang Han Lun and Jin Gui Yao Lue with its’ emphasis on reestablishing the qi mechanism of the body. Promoting the concept that if the qi can regulate disease doesn’t occur. Typical modifications of this formula

• For nausea and vomiting add Zhu Ru, Bambusa Caulis and Lu Gen, Phragmitis Rhizoma. (These herbs clear heat in the stomach and also benefit the lung and clear phlegm, so they reinforce the action of the other herbs in the formula for those conditions and are of particular benefit if foul smelling sputum is present.
• For pain and distension add Yu Jin, Curcuma Radix, Wu Yao, Lindera Radix. (This combination, the former for blood, the latter for qi, reinforces the invigorating effects of the formula.)
• For more cold obstruction in the chest add Xie Bai, Alliii Macrostemi, to reinforce the yang qi raising effects of the Cong Bai and Ban Xia, Pinellia Rhizoma, to reinforce the damp draining effect of the Xuan Fu Hua.
• For more heat appearing in the lung, such as dry cough and increased thirst add Gua Lou Pi, Trichosanthis Pericarpium, and Yu Xing Cao, Houttuyniae Herba.
• For coughing up blood add Xian He Cao, Agrimoniae Herba, and E Jiao, Asini Corii Colla. This combination stops bleeding while clearing heat and restoring damaged yin which has resulted from the heat and dryness above caused by the stagnation and fluid obstruction below of the Liver Fixity pattern.

The pathology of liver fixity

Now understanding the nature of Xuan Fu Hua Tang, we can further expand on the pathology of liver fixity. Commentators conflict on whether liver fixity (gan zhuo) is identical to liver distension (gan zhang). Liver distension is described in the Ling Shu chapter 35. When we compare the symptoms of liver distension from the Ling Shu and liver fixity from the Jin Gui, we see the overlap of stagnation symptoms with the Ling Shu indicating fullness beneath the ribs, and the Jin Gui indicating the desire for trampling.

The Ling Shu adds pain in the lower abdomen as a symptom. Although this is not mentioned in the Jin Gui item, the formula Xuan Fu Hua Tang is used for obstetrical and gynecological disorders and later practitioners have used the diagnosis of liver fixity as basis for treatment of lower warmer disorders as we will see when we examine the pathomechanism of liver fixity as described by the famous practitioner Ye Tian-shi.

Again comparing the information in the tables, we should note as well the similarity between kidney fixity as described in the Jin Gui and kidney distension as described in the Ling Shu. Their similarity can be taken as further proof of the overlap of fixity and distension. (We should also note that the formula used for kidney fixity is Gan Jiang Ling Zhu Tang, which warms the spleen yang in order to remove water from the area of the kidney.) Thus the pathomechanism described in the Ling Shu can broaden our understanding.

Table of symptoms of distension (Zhang) from Ling Shu Chapter 35, Items 5-9

Zang/Fu Zhang Zheng
Symptoms
Heart Depressed feeling, Shortness of breath, Restless sleep
Lungs
Chest Fullness, Wheezing, Cough
Liver
Fullness beneath the ribs, Pain in the lower abdomen
Spleen
Hiccup, Heaviness of the limbs, Heavy body, Dream disturbed sleep Kidneys
Fullness of abdomen with pain in the back and hips
Stomach
Abdominal swelling
Large Intestine
Borborygmus, diarrhea with undigested stool with cold
Small Intestine
Dullness and swelling of lower abdomen, Pain in low back
Bladder Swelling of lower abdomen, Inhibited urination
San Jiao Edema of skin which is floating and not hard
Gall Bladder Pain and swelling below the ribs, bitter taste in mouth, sighing

Table of disorders and symptoms from Jin Gui Chapter 11
Disorder
Symptoms
Wind strike of liver
Twitching of head and eyes (head shakes and eyes jump), bilateral rib-side pain, stoops while walking, prefers sweets
Cold strike of liver Inability to raise the arms, Dryness at the tongue root, Sighing, Pain in the chest, Inability to turn onto one’s side, Vomiting with sweating after eating
Liver Fixity
The patient desires trampling on the chest, Before the acute stage he only desires hot drinks, Xuan Fu Hua Tang is indicated
Kidney Fixity
Generalized heaviness and lumbar coldness as if sitting in water, Absence of thirst with unihibited urination, normal appetite, This indicates the disease in the lower burner, Over time the patient manifests pain below the waist and feels as if carrying a belt of heavy coins.

Paraphrasing Ling Shu Chapter 35:

Distension occurs outside the zang and fu and applies pressure to the outside of these organs, causing the sensation of pressure in the chest or abdomen, or filling up the skin causing swelling. It affects the blood vessels or the zang or fu. A big and hard pulse is yang and indicative of an excess of pathogens, a retarded pulse is yin and indicative of a blockage of the flow of qi and blood causing distension. When Ying qi traveling in the meridians encounters wei qi traveling outside the meridians it will cause distension. When wei qi invades the meridians and travels between the muscles it ill cause distension of the skin.

As to treatment, the wei qi and the ying qi circulate in their own daily rhythm. When cold xie qi enters the body the zheng qi surges to meet it. This causes a disruption in the normal circulation of wei and ying and distension results. As a result, sedation with the needle should be done three times. Once for the pathogen, once for the wei qi, and once for the ying qi. This implies three depths of insertion as well. The needle must be inserted deeply enough to affect the ying qi level otherwise harmonization of the qi flow will not occur. Additionally, if tonification only is mistakenly applied (i.e. in a mixed syndrome with deficiency of qi and the excess distension), zheng qi will not be able to travel where it belongs to nourish the organs, the five shen will be disturbed, and more pathogens can enter. This view of the pathomechanism is very consistent with chapter 11 of the Jin Gui when taken as a whole which concerns itself with a progression of disorders starting with wind strike of an organ, then cold strike, then fixity (or alternatively damaged, straightened, etc.), then finally, the death of the organ.

The textbook Essentials of Chinese Medicine states that the Liver rules soothing and releasing, it maintains the smooth flow of the qi mechanism within the whole body, it facilitates movement, prevents blockage, it disperses and doesn’t compress. If the liver loses its soothing and draining function, then the qi mechanism of the whole body is impeded, including the Lung and Stomach, which are responsible for balancing the up and down flow of qi throughout the body. Furthermore, the Liver is associated with the Wood element, the Lung belongs to Metal and the Stomach is related to Earth. If the Liver is excessive then Wood might insult the Lung Metal or overpower the Stomach Earth. If the Liver loses its soothing and draining function and the Liver qi compresses a knot forms. This has a very direct influence on the Lung and Stomach qi mechanism. If the Lung and Stomach qi mechanism is inhibited, then up and down movement are blocked and the qi cannot flow, the Liver has no path of draining and dispersing and consequently will further stagnate and compress. The pathological influence is thus said to:

• Cross counterflow to invade the stomach and spleen. If liver qi invades the stomach, it results in nausea, vomiting, abdominal pain and distension. If there is diarrhea and distending downward pain it is liver-spleen disharmony.
• Ascent counterflow to carry phlegm upwards. This may result in plum-pit qi with a sensation of a lump in the throat. Phlegm and qi may accumulate in the throat resulting in goiter (phlegm nodule due to qi stagnation in throat).
• Affects the chong mai and ren mai, leading to menstrual pain, menstrual block, painful distension of the breasts, breast lumps, and menstrual irregularities.
• Disturbs the hun, with resulting depression, impatience, and exaggerated emotional response.
• Inhibit storage of liver blood resulting in liver blood vacuity with blood failing to nourish the sinews, eyes, and uterus.
• Qi stagnation turns to heat with mental excitation, insomnia, headache, palpitations, ear ringing, and red eyes.
• Liver wood insults Lung metal or “stab the lung”, with symptoms such as wheezing, shortness of breath or if the liver is hot, dryness symptoms of lung, throat, and mouth.

Although liver heat can damage the lung yin and cause dryness, In the Shang Han Lun and Jin Gui Yao Lue when issues related to thirst and fluids arise, they are usually in relationship either to febrile disease, where the heat has injured the fluids, or to situations in which there is a blockage of the fluid mechanism of the body. The Lung is the upper source of water. It frees and regulates the water passages. The stomach absorbs the water and grains. When hot fluids enter the stomach, they first relax and moderate the stomach symptoms. This may be another aspect of the desire for warm drinks in liver fixity.

As we can see, with liver’s tendency when it is stagnant to cross and ascent counterflow, and with the nature of Xuan Fu Hua Tang to reestablish the qi mechanism and open the collaterals, I think we can reject the Golden Mirror of Medicine’s assertion that Xuan Fu Hua tang does not fit liver fixity and must be a textural error.

The location for the symptom of “the patient often desires trampling on the chest” disturbs some commentators as they argue that if the liver is the root of the disorder the symptom should significantly appear on the rib-sides (flanks). But the symptoms appearing in the chest may be accounted for by the aforementioned lung involvement or by the fact that water qi is accumulating and affecting the more general area under the ribs (as occurs in conditions were we “drain the heart”). Modern practitioners speak of the “costal arch” which anatomically contains the liver and this rather large area is clearly dominated by the liver. (See the following diagram.)

The area labeled hypochondrium and epigastrium enveloped by the costal arch.

Liver Fixity in gynecology and other disorders

Ye Tian-shi describes liver fixity as often appearing in gynecology. It appears with an aversion to cold and yet the presence of heat. If herbs that disperse wind are mistakenly given (because the practitioner mistakes the condition as a simple wind-cold invasion) wind symptoms will actually increase as the liver belongs to wood, which relates to wind, and thus the liver wind will stir due to the surface dispersing wind releasing herbs. As the liver controls the sinews, the cold evil, which is the origin of the liver fixity, contracts the sinews, and this may affect the whole body. As the liver also controls the eyes, the cold blocking the liver may prevent the eyes from closing and cause sleeplessness. This shouldn’t be mistaken for insomnia due to heat.

When the liver qi mechanism dysfunctions, there will be a tendency for qi to flow upward and fail to descend. (Note the downward action of Xuan Fu Hua.) Thus constipation and urinary block can occur. If you were to mistakenly these symptoms by purgation or downward draining, a condition of “no food, no appetite, no stool, no sleep” can occur. If tonics are given in this condition, vacuity taxation symptoms can occur as the blood stasis intensifies. Tonifying treatment will not work until the obstructions have been removed. If the accumulation is impacting the lungs and chough is present, if the sputum develops a bad smell, then the accumulation is transforming to toxic heat and lung abcess is occurring. When there is a hollow aspect to the patient’s pulse it indicates that blood deficiency is occurring (which may be due to either stasis preventing the liver from storing blood, or from the spleen’s blood producing function being impaired).

Ye Tian-shi had several herbs he routinely added to Xuan Fu Hua Tang: Jiang Xiang, Yu Jin, Tao Ren, Dang Gui, and Su Geng. The first three herbs are a yao dui that alleviate chest and flank pain due to stagnant qi and blood stasis. He preferred Dang Gui Wei as it was more useful in moving blood, particularly in gynecological conditions. The Su Geng relieved tightness in the chest. Besides affecting the liver, these herbs have an effect on the stomach and lung and reinforce that action of Xuan Fu Hua Tang. The Jiang Xiang has the additional benefit of stopping bleeding when the Xuan Fu Hua Tang is used for the particular situation of bleeding during the second half of the pregnancy. The first half of the pregnancy is said to be yang,; the second half yin. An increasing amount of yin fluid and blood is accumulating in the women’s lower jiao and if the qi is unable to move it properly blood flows out of its’ normal pathway. It should be noted that Dr. Ye also recognized the usefulness of techniques like acupuncture, cupping, and bleeding technique applied over the stagnant areas of the chest and flanks in liver fixity as mentioned in his case histories.

Modern applications

A modern application for the concept of liver fixity has arisen and that is for patients with chronic viral hepatitis. These patients often have progressive liver damage that can develop relatively asymptomatically over a long period. The patient may experience nothing more than a mild sensation of distension over the liver area, but because of the vagueness of the symptom, it is typically dismissed. Other symptoms that may be present include nausea and fatique. The patient will have, however, elevated liver enzymes, indicating liver damage is occurring. Eventually hardening and cirrhosis of the liver will occur and often complete liver failure results, necessitating transplant. In about 2% of patients liver cancer develops.

The World Health Organization estimates about 170 million people are infected with hepatitis C worldwide. There is an interferon based treatment for chronic hepatitis C but several genotypes of the virus do not respond to the therapy, and there are many side effects. Many patients are therefore left to just wait and periodically monitor their liver function. Two important makers of progress for the disease may be checked. The first is the liver enzyme levels: aspartate aminotransferase (AST or SGOT) and alanine aminotransferase (ALT or SGPT). As the result of injury to liver cells, they are released into the bloodstream and often serve as a fairly specific indicator of liver status (particularly in the case of ALT). If the liver enzymes are within their normal limits, the amount of liver damaging occurring from the chronic infection is likely to be small. The second indicator is liver “stiffness”. This stiffness of the liver is measured by transient elastometry, a technique in which the rate of passage of ultrasound through the liver is measured. A parallel seems quite likely between the liver stiffness of modern biomedicine and the liver fixity of traditional Chinese medicine.

Case presentation

RT, women, age 46 presented with chronically elevated liver enzymes. Diagnosis of infection with hepatitis C had been made 6 years previously. Her viral subtype was judged to be nonresponsive to interferon therapy so her physician was simply monitoring her liver enzymes. The measurements had been holding at < 100 u./ml. This is slightly elevated over normal levels, but is not considered a worrisome level. Suddenly there was an increase to around 400u./ml. This was very worrisome to her physician and thus caused her to seek alternative treatment. The patient was slightly thin with a pale complexion. She was active and athletic but had felt some ongoing fatigue over the past few months. Her appetite was poor and she preferred warm drinks. She often had a dry mouth. She experienced a slight distension over the right rib-side, which increased her anxiety about her condition. She was slightly irritable. Her menstruation was regular with cramping on the first day of bleeding which could be alleviated by heat on the low abdomen. Her pulse was weak and wiry; her tongue was pale with a white coating and a red edge.

Prescription:

Xuan Fu Hua Tang adding Ji Gu Cao, Dang Gui, Dan Shen, Gou Qi Zi, Sheng Jiang After one week taking the formula the patient reported increased energy and had no rib-side discomfort. She continued the formula for another week and then had a blood test. The liver enzymes were around 200u./ml. The formula was then changed to drinking a mild tea containing Xiang Fu, Ji Gu Cao, Tai Zi Sheng, Gou Qi Zi, drunken periodically throughout the day. A blood test was taken after one month. Liver enzymes were now <100. (Additionally, the patient had her period and experienced no cramping.)

Case histories for other modern medical conditions appear in the literature and these includes:

• Myocardial ischemia
• Pulmonary heart disease
• Chronic gastritis
• Cirrhosis due to alcohol

Formula Discrimination

• Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood)

For this formula the severity of blood stagnation is greater and the cause is more heat rather that cold (or yang qi debility) causing the stagnation. (One distinguishing characteristic that helps distinguish the formulas is very constant symptoms indicating use of Xue Fu Zhu Yu Tang, and the on-again off-again symptoms indicating Xuan Fu Hua Tang.)
• Tong Qiao Huo Xue Tang (Unblock the Orifices and Invigorate the Blood Decoction)

This formula targets symptoms more in the head whereas Xuan Fu Hua Tang targets symptoms in the chest.
• Xiang Fu Xuan Fu Hua Tang (Cyperi and Inula Decoction)

This formula is for more dampness with thin fluids accumulating in the chest.
• Xuan Fu Hua Dai Zhe Shi Tang (Inula and Hematite Decoction)

This formula focuses more on the stomach with symptoms of hiccup and regugitation. There is glomus in the stomach with weak qi.)
• Ban Xia Hou Po Tang (Pinellia and Magnolia Bark Decoction)

This formula targets qi stagnation (often due to emotional factors) that prevent the lungs and stomach from descending and phlegm accumulates in the throat.
• Chai Po Tang

This formula is particularly effective when liver stagnation blocks the lung qi resulting in wheezing. It is particularly effective in children’s asthma.
• Sheng Jiang Xie Xin Tang (Fresh Ginger Drain the Epigastrium Decoction)

This formula targets the stomach more directly to clear accumulated water and direct qi downward. (Compare with Ban Xia Xie Xin Tang and Gan Cao Xie Xin Tang.)
• Wen Jing Tang (Flow-warming Decoction)

This formula is for obstruction in the chong and ren mai there is more cold and deficiency below and more heat above.

Syndrome differentiation

As liver fixity encompasses all aspects of Liver distension also know as liver stagnation or binding depression of the liver, one should keep in mind all of the syndromes that are related to it, including:
• Liver qi stagnation due to qi deficiency
• Liver qi stagnation due to liver blood deficiency
• Liver qi stagnation with blood stasis
• Liver qi stagnation with heat
• Liver qi stagnation with spleen qi vacuity
• Liver qi stagnation with liver and kidney yin vacuity

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