Treatment using medicinal substances. In China, medicinal therapy is the main form of Chinese medical therapy.

The products used in Chinese medicine are generally lightly processed substances of plant, mineral, or animal origin. They are prescribed in formulas that the patient typically consumes daily for several days or weeks for medical conditions. Chinese medicinals are also frequently used in medicinal cookery, such as medicinal chicken soup or other recipes to support general health in the absence of disease.

Medicinal Properties and Actions (性能功效 xìng néng gōng xiào)

Medicinals are assigned properties, actions, and indications, which provide the rationale for their use. They are usually used in combinations called formulas. Formulas are prepared in various forms (decoctions, pills, powders, etc).

Properties of Medicinals

The effects of Chinese medicinal substances are understood in terms of their nature (heat and cold), their flavor, the channels that they act upon, and their tendency to move upward and outward or inward and downward. In addition, each medicinal is known to have specific actions, which are mostly explained by their nature, flavor, and channel entry.

Nature: Medicinals are classified as cold, cool, warm, or hot in nature, depending on the degree to which they cool or warm the body. These are called the four natures (四性 sì xìng) or the four qì (四气 sì qì). In addition, some medicinals are classified as neutral or balanced, which is sometimes cited as a fifth nature.

Chinese medicine is allopathic in nature, which means that warm-natured medicinals, such as fù zǐ (Aconiti Radix Lateralis Praeparata) and gān jiāng (Zingiberis Rhizoma), are used to treat cold conditions, while cold-natured agents such as dà huáng (Rhei Radix et Rhizoma) are used to treat hot conditions (like constipation with vigorous heat effusion).

Nonetheless, this rule is by no means rigid. Cold medicinals can be used for cold patterns and hot ones for heat patterns when they possess specific actions that would be helpful for the condition. However, they must be appropriately balanced in the formula by other medicinals of the opposite nature.

Flavor: Each agent is ascribed one or more of five flavors (五味 wǔ wèi): sour, bitter, sweet, acrid, and salty (酸 suān,苦 kǔ,甘 gān,辛 xīn,咸 xián). These are each associated with the five phases and are therefore in theory said to enter the channel, viscus, and bowel that correspond to the same phase.

• Sourness enters the liver (酸入肝 suān rù gān)
• Bitterness enters the heart (苦入心 kǔ rù xīn)
• Sweetness enters the liver (甘入脾 gān rù pí)
• Acridity enters the lung (辛入肺 xīn rù fèi)
• Saltiness enters the kidney (咸入肾 xián rù shèn)

In practice, however, this is not always the case, and other characteristics are often more salient.

• Sour agents not only enter liver-wood but, more importantly, have an astringent action.
• Bitter agents not only enter heart-fire but also have a drying and draining action.
• Sweet agents not only enter spleen-earth but also have a supplementing and relaxing effect.
• Acrid medicinals not only enter lung-metal but also a dispersing and moving action. Certain acrid medicinals are used for exterior patterns.
• Salty medicinals enter kidney-water; they can also soften hardness and act as a laxative for dry intestines.

Furthermore, the bowels and viscera that an agent affects are not necessarily those that a given flavor is said to enter, as explained below. For these reasons, it is important to understand that the five-phase correspondences between flavors and viscera represent an ancient theory that was reevaluated through practice.

Channel entry (归经 guī jīng): Each medicinal is said to enter one or more channels and their associated bowel or viscus. The channel entries of agents are largely based on the affinities of flavors with the viscera described above. However, this is not always the case. For example, hú táo rén (Juglandis Semen) is said to enter the kidney and lung channels but is described as sweet. In general, the channel entries of medicinals reflect their actions (see Actions below).

Toxicity (毒性 dú xìng): In ancient texts, toxic medicinals denoted materials that had curative properties in general and biases in terms of nature and flavor, in contradistinction to non-toxic ones, which were considered to have life-extending properties. Every medicinal has a specific nature and can have unwanted side effects, especially when used incorrectly. However, over the centuries the term toxicity came to denote marked side effects, and terms such as great toxicity and minor toxicity came to be used as warnings for regularly occurring side effects associated with specific agents if correctly used and within standard dosage ranges.

Bearing (升降浮沉 shēng jiàng fú chén): Many medicinals are ascribed a bearing, that is, one of four movements (upbearing, downbearing, floating, and sinking) that cause the medicinal action to affect different parts of the body.

• Upbearing (升 shēng) is upward movement. Upbearing medicinals affect the upper body.
• Downbearing (降 jiàng) is downward movement. Downbearing medicinals affect the lower body.
• Floating (浮 fú) is outward movement. Floating medicinals act on the exterior.
• Sinking (沉 chén) is inward movement. Sinking medicinal act on the interior.

Very often, upbearing and floating are considered to be one category in contradistinction to downbearing and sinking. Hence, the combination terms upfloating (升浮 shēng fú) and downsinking (降沉 jiàng chén) are often used.

Conditions marked by a downward or inward orientation, such as diarrhea, prolapse of the rectum, or clouded spirit (where, as it were, the spirit is blocked inside), are treated with upfloating medicinals, while those characterized by an upward or outward orientation, such as vomiting, cough, or sweating are treated with downsinking medicinals.

Spontaneous sweating and night sweating are outward movements and are treated by sinking medicinals. An exterior pattern failing to resolve with inward movement of the evil is an inward action and can be treated by floating medicinals.

Vomiting, panting and cough are upward movements and are treated by downbearing agents. Flooding and spotting (heavy and light pathological bleeding via the vagina) and diarrhea are downward movements and are treated by upbearing agents.

Note that these examples are of actions to counteract the abnormal movements of qì, blood, and fluids, which are all bodily substances. This is different from the examples given under helping things along their course above, which involve getting evils out of the body by the shortest route possible.

Sometimes, medicinals of one bearing are used in a formula to affect the bearing of other agents. For example, niú xī (Achyranthis Bidentatae Radix) is a downsinking agent that is sometimes used to direct the medicinal effect of other agents down to the lower body.

Actions

Medicinals each have one or more specific actions that affect the body in different ways. These include the following:

• Evil-dispelling actions, such as clearing heat or transforming dampness.
• Actions that restore bodily functions to normal, such as securing and astriction, opening the orifices, or rectifying qì.
• Supplementing actions that enhance substances or aspects of the body, e.g., supplementing qì, supplementing the blood, supplementing yīn, or supplementing yáng.

Many medicinals have multiple actions. For example, shēng jiāng (Zingiberis Rhizoma Recens) not only promotes sweating and resolves the exterior; it also warms the center and checks vomiting. Since the first of these two actions is considered the main one, most materia medica texts classify shēng jiāng as an exterior-resolving medicinal. In some cases, where opinion differs as to which is the main action, classification may differ between texts.

Methods of Treatment

Methods of treatment largely correspond to actions. They provide the basis for classifying medicinals in the modern materia medica literature. Some methods include subcategories.

1. Resolving the exterior (解表 jiě biǎo) is the method of regulating sweating and dispersing evils in the treatment of exterior patterns in externally contracted disease. A distinction between warm and cold medicinals is reflected in two subcategories:

• Warm acrid exterior-resolving medicinals, such as má huáng (Ephedrae Herba) and guì zhī (Cinnamomi Ramulus), treat wind-cold patterns.
• Cool acrid exterior-resolving medicinals, such as bò hé (Menthae Herba) and gé gēn (Puerariae Radix), treat wind-heat patterns.

Most exterior-resolving medicinals are acrid and upfloating. Most enter the lung channel; many enter the bladder channel.

2. Clearing heat (清热 qīng rè) is the method used to treat internal heat. Heat-clearing medicinals are divided into five classes:

• Heat-clearing fire-draining medicinals, such as shí gāo (Gypsum Fibrosum), clear pure repletion heat.
• Heat-clearing dampness-drying medicinals, such as huáng qín (Scutellariae Radix), address damp-heat.
• Heat-clearing blood-cooling medicinals, such as shēng dì huáng (Rehmanniae Radix), treat frenetic movement of hot blood.
• Heat-clearing toxin-resolving medicinals, such as jīn yín huā (Lonicerae Flos), treat virulent forms of heat that are marked by redness, swelling, and pain.
• Vacuity-heat–clearing medicinals, such as qīng hāo (Artemisiae Annuae Herba) and bái wēi (Cynanchi Atrati Radix), treat yīn vacuity with internal heat.

Heat-clearing medicinals are generally cold, bitter, and downbearing. Those that nourish yīn are sweet.

3. Draining-precipitation (泻下 xiè xià), also called purgation, is the method used to free the bowels. Medicinals classed as precipitants are divided into three classes:

• Offensive precipitants, such as dà huáng (Rhei Radix et Rhizoma), clear heat and free the stool in cases of repletion constipation.
• Moist precipitants, such as huǒ má rén (Cannabis Fructus), moisten the intestines to free the stool in cases of constipation due to fluid insufficiency.
• Drastic water-expelling medicinals, such as gān suì (Kansui Radix), promote evacuation of water through the stool in the treatment of ascites and severe distension.

Draining-precipitant medicinals are cold in nature. Most are bitter in flavor, but some are sweet and some are acrid. Most enter the large intestine channel. They are downsinking.

Note that the term 泻下 xiè xià Is often called purgation in English. We use the term draining precipitation to reflect the composition of the Chinese terms: 泻 xiè is to drain, while is to 下 xià, means down, to descend, or as here, to cause to descend.

4. Dispelling wind-damp (祛风湿 qū fēng shī) is the method used to treat wind-damp causing impediment (bì) pain. Wind-damp–dispelling medicinals are divided into three categories:

• Wind-damp–dispelling cold-dispelling medicinals, such as dú huó (Angelicae Pubescentis Radix, pubescent angelica) and wēi líng xiān (Clematidis Radix, clematis), treat cold impediment.
• Wind-damp–dispelling heat-clearing medicinals, such as qín jiāo (Gentianae Macrophyllae Radix) and fáng fēng (Saposhnikoviae Radix), treat heat impediment.
• Wind-damp–dispelling sinew-bone–strengthening medicinals, such as wǔ jiā pí (Acanthopanacis Cortex) and sāng jì shēng (Taxilli Herba), treat impediment with vacuity signs.

Wind-damp–dispelling medicinals are mostly warm, but those that dispel wind-damp-heat tend to be cold. Most are acrid or bitter in flavor. Most enter the liver channel, and many enter the kidney channel. The warm acrid ones are upbearing; the cold bitter ones are downsinking.

5. Transforming dampness (化湿 huà shī) is the method used to treat damp turbidity obstructing the center. Because most medicinals in this category have a strong aroma, they are also called aromatic dampness-transforming medicinals. Commonly used dampness-transforming medicinals include cāng zhú (Atractylodis Rhizoma), hòu pò (Magnoliae Officinalis Cortex), huò xiāng (Pogostemonis Herba), and bái dòu kòu (Amomi Fructus Rotundus).

Most dampness-transforming medicinals enter the spleen or stomach channel. There are no subcategories.

6. Disinhibiting water and percolating dampness (利水渗湿 lì shuǐ shèn shī) is the method of freeing the waterways in the treatment of water and dampness (water-damp) collecting internally and causing it to flow out with the urine. Several subcategories exist:

• Water-disinhibiting swelling-dispersing medicinals, such as fú líng (Poria) and yì yǐ rén (Coicis Semen), treat water swelling.
• Urine-disinhibiting strangury-freeing medicinals, such as chē qián zǐ (Plantaginis Semen) and huá shí (Talcum), treat strangury.
• Dampness-disinhibiting jaundice-abating medicinals, such as yīn chén hāo (Artemisiae Scopariae Herba) and hǔ zhàng (Polygoni Cuspidati Rhizoma), treat jaundice.

Water-disinhibiting dampness-percolating medicinals are predominantly cool-cold in nature and bland, sweet, or bitter in flavor. Most enter the kidney channel. They are generally downsinking.

7. Warming the interior (温里 wēn lǐ) is the method used to treat interior repletion cold when external cold evil strikes the interior directly. In addition to treating internal conditions of repletion cold, interior-warming medicinals are used to warm yáng (although they are not directly supplementing substances). Examples include fù zǐ (Aconiti Radix Lateralis Praeparata), ròu guì (Cinnamomi Cortex), and gān jiāng (Zingiberis Rhizoma).

Interior-warming agents are mostly warm or hot in nature and acrid in flavor and enter the spleen and stomach channels. There are no subcategories.

8. Rectifying qì (理气 lǐ qì) is the method used to treat qì stagnation or qì counterflow from a variety of causes. Medicinals in this category are often combined with medicinals in other categories, since qì stagnation is a contributing factor in many abnormal conditions. Qì-rectifying medicinals include chén pí (Citri Reticulatae Pericarpium), mù xiāng (Aucklandiae Radix), and zhǐ shí (Aurantii Fructus Immaturus).

Qì-rectifying medicinals are generally warm in nature and acrid in flavor. There are no subcategories.

9. Dispersing food (消食 xiāo shí) is the method used to treat food stagnation and accumulation in the digestive tract. Commonly used food-dispersing agents include shān zhā (Crataegi Fructus) and lái fú zǐ (Raphani Semen). They are mostly balanced in nature and sweet in flavor. There are no subcategories.

10. Expelling worms (驱虫 qū chóng) is the method traditionally used for conditions attributable to worms visible with the naked eye. In modern times, however, their use has been expanded to treat a wider range of parasites. shǐ jūn zǐ (Quisqualis Fructus), bīng láng (Arecae Semen), hè shī (Carpesii Fructus), and fěi zǐ (Torreyae Semen) are examples of commonly used medicinals. There are no subcategories.

11. Stanching bleeding (止血 zhǐ xuè) is the method used to treat pathological bleeding. Blood stanching medicinals are divided into several classes:

• Blood-cooling blood-stanching agents, such as dà jì (Cirsii Japonici Herba seu Radix), xiǎo jì (Cirsii Herba), and dì yú (Sanguisorbae Radix), are used to treat bleeding resulting from frenetic movement of hot blood.
• Stasis-transforming blood-stanching medicinals, such as sān qī (Notoginseng Radix) and qiàn cǎo(Rubiae Radix), are used for conditions of blood stasis that causes bleeding.
• Astringent blood-stanching agents, such as bái jí (Bletillae Rhizoma) and xiān hè cǎo (Agrimoniae Herba), are used for conditions in which there is no blood stasis.
• Channel-warming blood-stanching medicinals, such as pào jiāng (Zingiberis Rhizoma Praeparatum) and ài yè (Artemisiae Argyi Folium), are used for treating cold patterns with bleeding, like flooding and spotting or bloody stool.

Blood-stanching medicinals are mostly cool-cold in nature, although some are warm or balanced. They are sour/astringent, bitter, or acrid in flavor.

12. Quickening the blood and transforming stasis (活血化瘀 huó xuè huà yū) is the method used to treat blood stasis. Blood-quickening stasis-transforming medicinals are divided into three classes:

• Blood-quickening pain-relieving medicinals, such as chuān xiōng (Chuanxiong Rhizoma) and yán hú suǒ (Corydalis Rhizoma), treat blood stasis with pain.
• Blood-quickening menses-regulating medicinals, such as dān shēn (Salviae Miltiorrhizae Radix) and hóng huā (Carthami Flos), treat menstrual irregularities resulting from blood stasis.
• Blood-quickening external injury medicinals, such as zhè chóng (Eupolyphaga seu Steleophaga) and zì rán tóng (Pyritum), treat blood stasis resulting from external injury (e.g., bruises).
• Blood-quickening concretion-dispersing medicinals, such as é zhú (Curcumae Rhizoma), sān léng (Sparganii Rhizoma), and shuǐ zhì (Hirudo), disperse concretions and accumulations.

Blood-quickening stasis-transforming medicinals are warm or cool-cold in nature. They are largely acrid in flavor, although some are bitter. Some are upfloating and some are downsinking.

13. Transforming phlegm, suppressing cough, and calming panting (化痰止咳平喘 hù tán zhǐ ké píng chuǎn) are the actions used to treat phlegm patterns, cough, and panting. Tangible phlegm gives rise to cough and panting; while intangible phlegm causes numerous other conditions, such as wind stroke, epilepsy, scrofula, and phlegm nodes. Because most phlegm-transforming medicinals can suppress cough and calm panting, and because most agents that suppress cough and calm panting also treat phlegm patterns in general, the distinction between tangible and intangible phlegm does not impose further subcategorization.

• Phlegm-transforming medicinals, such as bàn xià (Pinelliae Rhizoma), tiān nán xīng (Arisaematis Rhizoma), and bái fù zǐ (Typhonii Rhizoma), are used to treat phlegm in general.
• Cough-relieving panting-calming medicinals, such as xìng rén (Armeniacae Semen), zǐ sū zǐ (Perillae Fructus), bǎi bù (Stemonae Radix), and zǐ wǎn (Asteris Radix), treat cough and/or panting.

Phlegm-transforming, cough-suppressing, and panting-calming medicinals are either warm or cool in nature. Many are bitter or acrid in flavor. Some phlegm-transforming medicinals are upfloating. Cough-suppressing panting-calming medicinals are generally downsinking.

14. Quieting the spirit (安神 ān shén) is the method used for heart vexation and insomnia. Spirit-quieting medicinals are divided into two categories: heavy settling spirit-quieting medicinals, which are typically of mineral origin, and heart-nourishing spirit-quieting medicinals, which are plant products.

• Heavy settling spirit-quieting medicinals, zhū shā (Cinnabaris), cí shí (Magnetitum), lóng gǔ (Mastodi Ossis Fossilia), and hǔ pò (Succinum), which as minerals are heavy in weight and have a calming action suitable for the treatment of mania and withdrawal or heart palpitation.
• Heart-nourishing spirit-quieting medicinals, such as suān zǎo rén (Ziziphi Spinosi Semen), bǎi zǐ rén (Platycladi Semen), and yuǎn zhì (Polygalae Radix), which treat conditions of the spirit attributable to heart yīn vacuity or heart blood vacuity.

Spirit-quieting medicinals are mostly balanced in nature and sweet in flavor. The heavy settlers are downsinking.

15. Calming the liver and extinguishing wind (平肝熄风 píng gān xī fēng)is the method used to treat ascendant hyperactivity of liver yáng and liver wind stirring internally.

• Liver-yáng–calming medicinals include shí jué míng (Haliotidis Concha), zhēn zhū mǔ (Concha Margaritifera), mǔ lì (Ostreae Concha), and dài zhě shí (Haematitum).
• Wind-extinguishing wind and tetany-settling medicinals,which treat pronounced spasm resulting from liver wind stirring internally, include niú huáng (Bovis Calculus), zhēn zhū (Margarita), gōu téng (Uncariae Ramulus cum Uncis), tiān má (Gastrodiae Rhizoma), dì lóng (Pheretima), and quán xiē (Scorpio).

Liver-calming wind-extinguishing medicinals are cold or balanced in nature and bitter or salty in flavor. They are generally downsinking.

16. Opening the orifices (开窍 kāi qiào) is the method used to treat clouding of spirit (loss of consciousness) in block patterns but not in vacuity or desertion patterns). Note that orifices refer to the orifices of the heart, which is an abstract entity, rather than an anatomical one. When the orifices of the heart are open, a person is conscious; when the orifices of the heart are closed, the patient is unconscious. The chief orifice-opening medicinals are shè xiāng (Moschus), bīng piàn (Borneolum), sū hé xiāng (Styrax), and shí chāng pú (Acori Tatarinowii Rhizoma).

Orifice-opening medicinals are generally warm in nature, acrid/aromatic in flavor, and upbearing. There are no subcategories.

Note that orifice-opening medicinals are not used in clouded spirit occurring in vacuity patterns.

17. Supplementation (补益 bǔ yì) is the method used to treat vacuity.

• Qì-supplementing medicinals, such as rén shēn (Ginseng Radix), dǎng shēn (Codonopsis Radix), huáng qí (Astragali Radix), and dà zǎo (Jujubae Fructus), address qì vacuity.
• Yáng-supplementing medicinals, such as lù róng (Cervi Cornu Pantotrichum), dōng chóng xià cǎo (Cordyceps), gé jiè (Gecko), hú táo rén (Juglandis Semen), treat yáng vacuity. Many of them have specialized uses that address specific functions. For example, yín yáng huò (Epimedii Herba) has the action of invigorating yáng (壮阳 zhuàng yáng), which enhances male sexual performance; gé jiè (Gecko) promotes the kidney’s qì-absorption function and supplements lung qì.
• Blood-supplementing medicinals, such as dāng guī (Angelicae Sinensis Radix), shú dì huáng (Rehmanniae Radix Praeparata), and hé shǒu wū (Polygoni Multiflori Radix), address blood vacuity.
• Yīn-supplementing medicinals, such as shā shēn (Glehniae Radix), mài dōng (Ophiopogonis Radix), tiān dōng (Asparagi Radix), guī bǎn (Testudinis Carapax et Plastrum), biē jiǎ (Trionycis Carapax), treat yīn vacuity.

Supplementing medicinals vary in nature but are generally sweet in flavor. Yáng-supplementing medicinals are mostly warm. Many blood-supplementing medicinals are warm. Qì-supplementing medicinals are mostly warm or balanced. Yīn-supplementing medicinals are mostly cool-cold. Some human or animal products are salty. Some qì-supplementing and many yīn-supplementing medicinals are bitter.

Fù zǐ (Aconiti Radix Lateralis Praeparata, aconite), and ròu guì (Cinnamomi Cortex, cinnamon bark), which are usually classified as interior-warming medicinals, also supplement yáng (they are said to supplement fire).

Several yīn-supplementing medicinals, notably shā shēn (Glehniae Radix), mài dōng (Ophiopogonis Radix), tiān dōng (Asparagi Radix), shí hú (Dendrobii Herba) and bǎi hé (Lilii Bulbus), also clear heat.

18. Securing and astriction (固涩 gù sè), or simply astriction, is the method used to stem loss of fluid in the treatment of sweating, chronic diarrhea, seminal emission, and severe vaginal discharge.

• Sweat-checking medicinals include má huáng gēn (ephedra root, Ephedrae Radix), fú xiǎo mài (Tritici Fructus Levis), and nuò dào gēn (Oryzae Glutinosae Radix).
• Diarrhea-checking medicinals include wǔ wèi zǐ (Schisandrae Fructus), wū méi Mume Fructus), wǔ bèi zǐ (Galla Chinensis), and yīng sù qiào (Papaveris Pericarpium).
• Essence-securing, urine-reducing, and discharge-checking medicinals such as, shān zhū yú (Corni Fructus), fù pén zǐ (Rubi Fructus), sāng piāo xiāo (Mantidis Oötheca), hǎi piāo xiāo (Sepiae Endoconcha), and jīn yīng zǐ (Rosae Laevigatae Fructus), treat seminal emission, profuse urination, and vaginal discharge.

astringing medicinals are largely balanced or warm in nature, and sour/astringent in flavor. Some phlegm-transforming medicinals, namely those that soften the hardness of scrofula and phlegm nodes, are salty.

19. Ejection (涌吐 yǒng tù) is the method used to cause vomiting to eject unwanted matter not only from the stomach but also the throat and chest, such as phlegm turbidity and phlegm-drool in the chest and diaphragm. They include guā dì (Melonis Pedicellus), cháng shān (Dichroae Radix), shǔ qī (Dichroae Folium), and lí lú (Veratri Nigri Radix et Rhizoma). Ejection medicinals are varying in nature and bitter in flavor.

20. External use (外用 wài yòng) is the topical application of medicinals. Medicinals for external use are used to treat welling-abscesses, flat-abscesses, boils, clove sores, lichen, scab, and other lesions of the skin and flesh.

• Toxin-attacking, worm-killing, and itch-relieving medicinals include xióng huáng (Realgar), liú huáng (Sulphur), bái fán (Alumen), and shé chuáng zǐ (Cnidii Fructus).
• Toxin-drawing, putridity-transforming, and flesh-engendering medicinals include qiān dān (Minium), qīng fěn (Calomelas), lú gān shí (Calamina), péng shā (Borax), and zhāng nǎo (Camphora).

Indications

Indications are the conditions that an agent treats. Usually, these are:

• disease names (e.g., measles, impediment, strangury), including major symptoms that are traditionally considered as diseases (e.g., cough, abdominal pain, headache, diarrhea);
• symptom names (e.g., painful red swollen eyes); or
• disease names qualified either by pattern names or by symptoms (lung heat cough, damp-heat strangury, thirst in febrile disease).

Unqualified pattern names only rarely appear amongst the indications. An indicated disease that can take the form of different patterns is not necessarily always treated by the medicinal in question. However, indications are always viewed in the context of their actions, which indicate pattern types for which the medicinal is suited.

Contraindications

Some medicinals are contraindicated (禁忌 jìn jì) under certain conditions. This means they should not be taken under the specified condition(s). Other medicinals are to be used with care, which means they can be used sparingly, but care must be taken to minimize side effects.

There are four kinds of contraindication of medicinals: combinative contraindications, pregnancy contraindications, pattern contraindications, and dietary contraindications.

Combinative contraindications: The combinative contraindications of a medicinal are injunctions against its use with another medicinal or medicinals. In the seven relationships described further ahead, aversion and clashing are in effect combinative contraindications. Over the centuries, there has been considerable disagreement about what medicinals should not be used in combination. In the Jīn-Yuán period, combinative contraindications were formulated into the nineteen fears and the eighteen clashes. Other slightly different sets of rules were offered in later literature, but these two became the universal standard.

The nineteen fears (十九畏 shí jiǔ wèi) are nineteen medicinals standing in a relationship in which the action or toxicity of one medicinal is reduced or completely destroyed by another or other medicinals. (Note that fear in the nineteen fears is not to be confused with fearing among the seven relationships described further ahead.)

• Liú huáng (Sulphur) fears pò xiāo (Natrii Sulfas Non-Purus).
• Shuǐ yín (Hydrargyrum) fears pī shuāng (Arsenicum Sublimatum).
• Láng dú (Stellerae seu Euphorbiae Radix) fears mì tuo2 sēng (Lithargyrum).
• Bā dòu (Crotonis Fructus) fears qiān niú zǐ (Pharbitidis Semen).
• Dīng xiāng (Caryophylli Flos) fears yù jīn (Curcumae Radix).
• Chuān wū(Aconiti Radix, aconite main tuber) and cǎo wū(Aconiti Kusnezoffii Radix) fear xī jiǎo (Rhinocerotis Cornu).
• Yá xiāo (Natrii Sulfas Equus-Dentatis, horsetooth mirabilite) fears sān léng (Sparganii Rhizoma, sparganium).
• Ròu guì (Cinnamomi Cortex) fears chì shí zhī (Halloysitum Rubrum).
• Rén shēn (Ginseng Radix, ginseng) fears wǔ líng zhī (Trogopteri Faeces).

The eighteen clashes (十八 反 shí bā fǎn) are eighteen incompatibility relationships between medicinals:

• Gān cǎo (Glycyrrhizae Radix, licorice) clashes with dà jǐ (Euphorbiae seu Knoxiae Radix), hǎi zǎo (Sargassum), yuán huā (Genkwa Flos), and gān suì (Kansui Radix).
• Wū toú (Aconiti Radix Wutou) clashes with chuān bèi mǔ (Fritillariae Cirrhosae Bulbus), zhè bèi mǔ (Fritillariae Thunbergii Bulbus), guā loú (Trichosanthis Fructus), bàn xià (Pinelliae Rhizoma), bái liǎn (Ampelopsis Radix), and bái jí (Bletillae Rhizoma).
• Lí lú (Veratri Nigri Radix et Rhizoma) clashes with rén shēn (Ginseng Radix), shā shēn (Adenophorae seu Glehniae Radix), dān shēn (Salviae Miltiorrhizae Radix), xuán shēn (Scrophulariae Radix), kǔ shēn (Sophorae Flavescentis Radix), xì xīn (Asari Herba), bái sháo yào (Paeoniae Radix Alba), and chì sháo yào (Paeoniae Radix Rubra).

Pregnancy contraindications: Many medicinals can damage the fetus and hence are contraindicated in pregnancy. A few examples are given below; the full list is much longer.

• Draining-precipitant dà huáng (Rhei Radix et Rhizoma) and máng xiāo (Natrii Sulfas)
• Blood-quickening yán hú suo3 (Corydalis Rhizoma) and yù jīn (Curcumae Radix)
• Phlegm-transforming cough-suppressing panting-calming tiān nán xīng (Arisaematis Rhizoma) and bái fù zǐ (Typhonii Rhizoma)

Pattern contraindications: Certain medicinals are contraindicated in certain disease patterns. Examples:

• Má huáng (Ephedrae Herba) is acrid and warm. It promotes sweating and resolves the exterior, disperses wind-cold, and diffuses the lung, calms panting, and disinhibits urine. It treats either externally contracted wind-cold exterior patterns without sweating or non-diffusion of lung qì with cough and panting. It is contraindicated in spontaneous sweating caused by exterior vacuity, in night sweating resulting from yīn vacuity, and in lung-kidney vacuity panting.
• Huáng jīng (Polygonati Rhizoma), which enriches yīn and supplements the lung, as well as supplementing the spleen and boosting qì. It is mainly used for lung vacuity dryness cough, spleen-stomach vacuity, and kidney vacuity and essence depletion. Because it is rich and slimy in texture, it easily fosters dampness evil and hence is contraindicated in spleen vacuity with dampness and cough with copious phlegm.

Dietary contraindications: While taking certain medicinals, a patient should avoid certain foodstuffs. Ancient literature specified several dietary contraindications:

• scallions should not be eaten when taking cháng shān (Dichroae Radix);
• scallions, garlic, and Chinese radish should not be eaten when taking dì huáng (Rehmanniae Radix) or hé shǒu wū (Polygoni Multiflori Radix);
• turtle meat should not be eaten when taking bò hé (Menthae Herba);
• vinegar should not be eaten when taking fú líng (Poria);
• amaranth (a leafy vegetable not well known in the West) should not be eaten when taking biē jiǎ (Trionycis Carapax).

Raw and cold foods, sticky and clogging foods, fishy smelling foods, and foods that cause irritation or are difficult to digest should be avoided as far as possible while taking medication.

Foodstuffs unsuitable for specific conditions are given below.

• Cold patterns: Raw and cold foods; chilled beverages.
• Heat patterns: Hot spicy food, oily foods, and fried foods.
• Chest impediment: Animal fat, offal, alcohol (and smoking).
• Spleen-stomach vacuity: Deep-fried foods, sticky foods, cold foods, and solid foods that are difficult to digest.
• Water swelling: Salt.
• Hyperactivity of liver yáng with dizzy head and vision, impatience, agitation, and irascibility: Pepper, chili, garlic, and distilled liquor.
• Jaundice: Animal fat, hot spicy food, alcohol (and smoking).
• Sores: Fish, prawns, crab.

Processing (炮制 páo zhì)

The vast majority of medicinals undergo processing before they are ready to be made into their final preparation forms (decoctions, pills, powders, etc.).

Most medicinals undergo one or more acts of processing for one reason or another. Most medicinals must be sized (cut to an appropriate shape and size) for storage and final preparation. Some must be processed to reduce toxicity or side effects or to change their properties to suit specific therapeutic needs.

Of greatest interest to the practitioner are methods of processing designed to reduce toxicity and side-effects and change therapeutic actions. A few examples are given below.

Stir-frying (炒 chǎo) is tossing materials in a heated wok. It is important to know that stir-frying in medicinal processing, unless expressly stipulated, uses no oil. There are different degrees of stir-frying: stir-frying until yellow, scorch-frying, and char-frying.

• Stir-frying until yellow (炒黄 chǎo huáng) is stir-frying until the surface of the materials turns slightly yellow or gives an aroma. Niú bàng zǐ (Arctii Fructus) and zǐ sū zǐ (Perillae Fructus) stir-fried in this way makes their active ingredients more readily soluble in decoction.
• Scorch-frying (炒焦 chǎo jiāo) means applying a strong heat to make materials brown on the outside and yellowish on the inside. Mài yá (Hordei Fructus Germinatus) is scorch-fried to reduce its food-dispersing effect and enhance its spleen-fortifying effect.
• Char-frying (炒炭 chǎo tàn) is stir-frying until the outer surface of the materials is black and charred and the inside is browned. The materials are doused with water after heating in order to prevent further burning. This process is also referred to as nature-preservative burning (烧存性 shāo cun2 xing4). It is used to make ài yè tàn (Artemisiae Argyi Folium Carbonisatum), dì yú tàn (Sanguisorbae Radix Carbonisata), and pào jiāng (Zingiberis Rhizoma Praeparatum). Char-frying moderates the harshness of medicinals, reduces side effects, or increases their astringent or blood-stanching action.
• Stir-frying in sand(沙炒 shā chǎo) is stir-frying with ground huá shí (Talcum), or in hǎi gé fěn (Cyclinae (Meretricis) Concha Pulverata) to ensure that materials are heated evenly and become brittle. By this process, their active ingredients are brought out in decoction or makes them easier to take. Examples include ē jiāo (Asini Corii Colla) fried with clamshell powder.

Mix-frying (炙 zhì) is stir-frying medicinals with a liquid adjuvant that soaks into them, to either increase their effectiveness or to reduce their side effects. Adjuvant agents include honey, rice wine (also called yellow wine), vinegar, ginger juice, brine, and child’s urine.

• Gān cǎo (Glycyrrhizae Radix) and huáng qí (Astragali Radix) are mix-fried with honey to increase their center-supplementing qì-boosting effect.
• Xiāng fù(Cyperi Rhizoma) is mix-fried with vinegar to increase its ability to course the liver and relieve pain.
• Bǎi bù (Stemonae Radix) and kuǎn dōng huā (Farfarae Flos) are mix-fried with honey to increase their effect of moistening the lung and suppressing cough.
• Chuān xiōng (Chuanxiong Rhizoma) is mix-fried with wine to increase its blood-quickening effect.
• Dù zhòng (Eucommiae Cortex) is mix-fried with brine to increase its ability to supplement the kidney.
• Cháng shān (Dichroae Radix) is mix-fried with wine to decrease its emetic effect.

Calcination (煅 duàn) is heating materials until they become red hot to make them brittle and to fully exert their effects. Hard minerals and shells are usually subjected to direct calcination, whereby the materials are in direct contact with the flame and are heated until they become completely red hot. Animal and vegetable products, such as xuè yú tàn (Crinis Carbonisatus) and zōng lu92 tàn (Trachycarpi Stipulae Fibra Carbonisata), are subjected to indirect calcination whereby they are heated in a wok that becomes red hot at the bottom.

Roasting (煨 wèi) is a process whereby medicinals wrapped in a protective coating of wet flour or paper are heated in embers until the coating is charred. It reduces harshness and side effects such as irritation by partially removing volatile oils. Examples are roasted shēng jiāng (Zingiberis Rhizoma Recens), roasted gān suì (Kansui Radix), and roasted ròu dòu kòu (Myristicae Semen).

Boiling (煮 zhǔ) is the heating of materials in water or other liquid at boiling point. For example, yuán huā (Genkwa Flos) is boiled in vinegar to reduce its toxicity. Huáng qín (Scutellariae Radix) is boiled in rice wine to increase its ability to clear lung heat.

Steaming (蒸 zhēng) means placing materials over boiling water. Sometimes adjuvants are used. For instance, dà huáng (Rhei Radix et Rhizoma, rhubarb) soaked in wine and steamed reduces its precipitant effect. Some items are repeatedly steamed and sun-dried to obtain the desired therapeutic effects. For example, hé shǒu wū (Polygoni Multiflori Radix) is repeatedly steamed and dried to eliminate its precipitant effect and give it the properties of supplementing the liver and kidney and of boosting essence and blood.

Classification of Medicinals (中药分类 zhōng yào fēn lèi)

• Exterior-resolving agents
• Heat-clearing agents
• Draining-precipitant agents
• Wind-damp–dispelling agents
• Aromatic dampness-transforming agents
• Water-disinhibiting dampness-percolating agents
• Interior-warming agents
• Qì-rectifying agents
• Food-dispersing agents
• Worm-dispelling agents
• Blood-stanching agents
• Blood-quickening stasis-dispelling agents
• Phlegm-transforming cough-relieving panting-calming agents
• Spirit-quieting agents
• Liver-calming wind-extinguishing agents
• Orifice-opening agents
• Supplementing agents
• Astringent agents
• Ejection agents
• External medicine agents

Overview of Formulas

Formula Composition

The actions of medicinals are determined to a great degree by their combinations with other medicinals. Few agents are used alone; polypharmacy, the combination of multiple agents, is a distinguishing feature of Chinese medicine. This is based on the notion that specific agents will exert different actions depending on how they are combined with other medicinals in formulas. Agents interact with each other in different ways, either by strengthening or weakening each other’s action or by exacerbating or lessening each other’s toxicity or harshness. Formulas, rather than single medicinals, are thus the norm in clinical practice. Classical formulas exemplify virtually all potential treatment principles that exist; customized formulas are typically created by modifying classical formulas through the addition or omission of individual agents.

Guidelines for devising formulas include the seven relationships and the four roles.

The Seven Relationships

The seven relationships (七情 qī qíng) are guidelines for ensuring the most effective and least injurious treatment.

• Acting singly (单行 dān xíng): Also called going alone. The ability of an agent to be used for a specific purpose alone. For example, huáng qín (Scutellariae Radix) and rén shēn (Ginseng Radix) can act singly.
• Mutual need (相须 xiāng xū): Two medicinals’ need of each other to produce maximum effect; mutual strengthening. For example, shí gāo (Gypsum Fibrosum) and zhī mǔ (Anemarrhenae Rhizoma) combined have a more powerful heat-clearing fire-draining effect than when used singly. Dà huáng (Rhei Radix et Rhizoma) and máng xiāo (Natrii Sulfas) when combined have a far more potent offensive precipitation effect than when used individually.
• Empowering (相使 xiāng shǐ): The ability of a secondary agent to enhance the action of a chief agent. For example, fú líng (Poria) disinhibits water and fortifies the spleen, and this action is often used to strengthen the qì-supplementing and water-disinhibiting action of huáng qí (Astragali Radix).
• Fearing (相畏 xiāng wèi): The reduction or elimination of an agent’s toxicity or side effects by another agent. For example, the toxicity of bàn xià (Pinelliae Rhizoma) and raw tiān nán xīng (Arisaematis Rhizoma) is reduced or eliminated by shēng jiāng (Zingiberis Rhizoma Recens); hence they are said to fear shēng jiāng.
• Killing (相杀 xiāng shā): The ability of one agent to reduce or eliminate the toxicity or side effects of another. Examples: shēng jiāng (Zingiberis Rhizoma Recens) kills the toxin of bàn xià (Pinelliae Rhizoma); shè xiāng (Moschus) kills the toxin of xing4 rén (Armeniacae Semen); lu94 dòu (Phaseoli Radiati Semen) kills the toxin of bā dòu (Crotonis Fructus); raw honey kills the toxin of wū toú (Aconiti Radix Wutou). Killing and fearing are the same relationship described from different points of view.
• Aversion (相恶 xiāng wù): The weakening of one medicinal’s action by another medicinal. For example, rén shēn (Ginseng Radix, ginseng) is averse to lái fú zǐ (Raphani Semen), since its therapeutic effects are weakened by lái fú zǐ.
• Clashing (相反 xiāng fǎn): The creation of toxic reactions or side effects when two agents are used together.

The Four Roles

Most formulas are composed of several agents. Each agent performs a specific role in the formula. Most formulas have medicinals performing four distinct roles, expressed in governmental metaphors that originate with the Shén Nóng Běn Cǎo Jīng: sovereign, minister, assistant, and courier.

• The sovereign (君 jun1) performs the principal action of the formula, addressing the chief sign or pattern. The sovereign may be one or more medicinals.
• The minister (臣 chén) provides direct assistance to the sovereign.
• The assistant (佐 zuo3) addresses secondary patterns or signs or reduces the toxicity or harshness of the sovereign.
• The courier (使 shǐ) makes other medicinals act on the desired part of the body or harmonizes all the medicinals in the formula.

Medicinal Preparations (剂型 jì xíng)

A medicinal preparation is the final form in which a medicinal formula is used by the patient. There are preparations for oral and topical use. Preparations for oral administration include decoctions, pills, powders, or medicinal liquors. Preparations for topical application include pastes, plasters, steam washes, decoctions, and alcohol or vinegar extracts. The most commonly used preparation forms are described below.

Decoctions (汤 tāng,汤剂 tāng jì): The form in which Chinese medicinals are most commonly taken is as a decoction, that is, an orally administered liquid form made by boiling medicinals in water and removing the dregs. For internal use, decoctions generally offer the most potent and immediate results. Certain agents, such as dāng guī (Angelicae Sinensis Radix) contain volatile oils that are destroyed by prolonged boiling, so instructions in formulas will state add at the end (后下 hòu xià), that is, a few minutes before the end of the decocting time. Some items in a decoction are not boiled with the other ingredients but are mixed with a large amount of the decoction, so formula instructions will state drench.

Decoctions are usually prepared from a pack of medicinals (帖 tiě), which is usually a day’s dosage. The decoction is brewed, traditionally by the patient or caregiver, and split into three portions to be taken morning, noon, and night.

A decoction that is taken cool is called a beverage (饮 yǐn), while a beverage that can be taken at any time is called a drink (饮子 yǐn zi).

Decoctions have the disadvantage of being inconvenient to use, because the patient must brew them freshly every day. As a result, other traditional preparation forms such as pills or dried powders, have come to be used more widely over recent decades. New preparation forms have also evolved, notably the powder decoction, made by removing the water content from a decoction by methods similar to those used to make instant coffee. These powders are simply swallowed with water. People can carry them around and take them at any time.

Powders (散 sǎn, 散剂 sǎn jì): The traditional powder (as opposed to the modern powder-form decoction) is made by simply grinding medicinals. Powders are the preparation form used for potent or costly medicinals whose effects are damaged by decoction. They are taken orally or insufflated (blown) into the nose or throat. Medicinals have first to be ground to a powder if they are to be made into pills or plasters. Powders can also be applied topically. Formulas sometimes state they should be taken drenched or, in external use formulas, applied mixed, that is mixed with water, oil, or other fluid.

Pills (丸 wán,丸剂 wán jì): The traditional Chinese pills are made by combining finely ground medicinals with honey or other binding agents into large or small pills which may be chewed or swallowed. Pills are used for chronic conditions requiring mild but consistent, long-term treatment. Like powders, pills are a favored medium for medicinals that are extremely potent, valuable, or may be damaged by the heat of cooking.

Plasters (膏药 gāo yào): A paste mounted on a cloth, applied topically to the body. Pastes are made from oil in which medicinals have been fried.

Medicinal liquors (药酒 yào jiǔ): A preparation made by steeping medicinals in liquor. Medicinal liquors are traditionally used for long-term supplementation and involve prolonged steeping of medicinals in high-potency alcohol.

Classification of Formulas (方剂分类 fāng jì fēn lèi)

　
• Exterior-resolving formulas
• Draining-precipitant formulas
• Harmonization formulas
• Heat-clearing formulas
• Summerheat-dispelling formulas
• Interior-warming formulas
• Dual exterior-interior resolution formulas
• Supplementing formulas
• Astringing formulas
• Spirit-quieting formulas
• Orifice-opening formulas
• Qì-rectifying formulas
• Blood-rectifying formulas
• Wind-relieving formulas
• Dryness-relieving formulas
• Dampness-dispelling formulas
• Phlegm-dispelling formulas
• Dispersion formulas
• Worm-expelling formulas
• Ejection formulas
• External medicine formulas