October 2009 issue of Acupuncture Today, I wrote on how to use pulse diagnosis to distinguish patterns as excess, deficiency or complex excess with deficiency. I ended that article by saying that most complex layered cases that enter the clinic will show excess/deficiency patterns affecting the liver, stomach and spleen. Our job, as herbalists, is to evaluate the various stagnation and deficiency patterns and to apply the appropriate herbal formula." />
Acupuncture Today – April, 2010, Vol. 11, Issue 04

acupuncturetoday.com >> Herbs/ Teas & Homeopathy

Treating Complex Multilayered Cases, Part 2

By Jake Paul Fratkin, OMD, LAc

In the October 2009 issue of Acupuncture Today, I wrote on how to use pulse diagnosis to distinguish patterns as excess, deficiency or complex excess with deficiency.

I ended that article by saying that most complex layered cases that enter the clinic will show excess/deficiency patterns affecting the liver, stomach and spleen. Our job, as herbalists, is to evaluate the various stagnation and deficiency patterns and to apply the appropriate herbal formula.

As I have written in previous articles, most notably "Managing A Patient With Multiple Complaints," (Acupuncture Today, July 2008) patients coming in for the first time tend to have mixed excess and deficiency patterns. My recommendation is to prioritize liver stagnation for the first month. If their complaints are multiple, with symptoms occurring in various burners simultaneously (e.g., insomnia, menstrual cramps, abdominal bloating, etc.), it is best to start with a broad-purpose formula to move liver qi and blood. My preferred formula is Chai Hu Shu Gan Wan.1 This formula actually is an elaboration of Si Ni San ("Four Counter-Flow Powder").2 The original Si Ni San contains chai hu (Radix bupleurum), bai shao yao (Radix paeonia lactiflora), zhi ke (Fructus citrus aurantium), gan cao (Radix glycyrrhizae uralensis). To reinforce the formula's ability to move qi, xiang fu (Rhizoma cyperi rotundi) is added, as is chen pi (Pericarpium citrus reticulata), which helps descend stomach qi. To reinforce bai shao in moving liver blood, chuan xiong (Rhizoma ligustici wallichi) is added.

After one month, we can now more accurately prioritize the predominant pattern based on both symptoms and pulse. On the first visit, the patient has many complaints, but after one month of Chai Hu Shu Gan Tang, some of those complaints will be completely gone, while others have been significantly reduced. We now need to focus on the worst complaints by prioritizing the upper, middle or lower burner.

Upper Burner: If the worst complaints focus on insomnia and/or headache, we prioritize the upper burner. It is important to know if liver excess still plays a part, which is determined through pulses. If we find wiriness in the superficial aspect of the left guan-middle position, with a corresponding weakness in the deeper aspect of the same position, this shows that liver yang is rising. In more severe cases of liver yang rising, the superficial aspects of all the positions will be wiry, while the deeper aspect of every position will be weak in comparison. Even if it only shows on the left guan-middle position, this shows liver yang rising up along the gallbladder channel, which can create headache or insomnia.3 In this case, I recommend the classical formula Chai Hu Jia Long Gu Mu Li Tang.4 This formula uses Xiao Chai Hu Tang as its foundation and adds the heavy mineral sedating substances mu li (Concha ostrea)and long gu (Os draconis).

In some cases of headache and insomnia, the cause is actually liver fire rather than liver yang rising. These cases are rarer, and are confirmed by red sides along the tongue body and other signs such as redness to the eyes.5 The pulses may still demonstrate a sharp excess in the superficial guan-middle position, but it will also show some rapidity. In this case, the best treatment is Long Dan Xie Gan Tang, which cools liver and gallbladder fire.6

Middle Burner: Complaints include epigastric symptoms (acid reflux, local pain), feeling of fullness after eating, poor appetite or indigestion. It is important to distinguish excess alone, mixed excess and deficiency, or deficiency alone. Excess alone will show strong pulses of the superficial aspect of the guan-middle position on both right and left hands. The stomach position on the right hand will clearly show excess in comparison to its deeper aspect, the spleen. The treatment strategy is to clear liver excess by moving liver qi and blood, and to descend stomach qi. The treatment of choice is Shu Gan Wan, a modern patent medicine containing 18 herbs.7 This formula is for pure excess, containing six herbs that move liver qi and blood and 10 herbs that descend stomach qi and damp.8,9

If the excess is due to food stagnation, the pulses are also wiry in the superficial positions, but more importantly, the tongue shows a significant coat. Patients get full easily. In the absence of obvious liver qi stagnation, I would go with Bao He Wan in acute or chronic cases.10 In purely an acute case, I would recommend the patent medicine Kang Ning Wan.11

In mixed excess and deficiency, we again find wiry pulses in the superficial aspect, but with more noticeable weak or empty pulses in the deeper pulses of both the left and right guan-middle positions. The left side represents wood (gallbladder and liver), and the right represents earth (stomach and spleen). There can be variations here, but usually the excess is not as strong as in the pure excess state described above. There is still a slight wiry quality to the floating aspect of the pulse. Both spleen and liver will be weaker than their corresponding stomach and gallbladder positions. While excess signs of stagnation are still obvious (abdominal distension, discomfort after eating), the history shows some chronicity of symptoms. The formula I would recommend is Xiang Sha Yang Wei Tang.12 This is similar to Xiang Sha Liu Jun Zi Tang and many people feel it is a variation of that formula, but Xiang Sha Yang Wei Tang actually predates Xiang Sha Liu Jun Zi Tang by 88 years.13 In Xiang Sha Yang Wei Tang, we have a foundation that supports spleen qi (bai zhu, fu ling, gan cao, da zao, gan jiang), while reinforcing with herbs to descend stomach qi and dampness (chen pi, ban xia, mu xiang, huo xiang, xiang fu, bai dou kou, hou po, sha ren and zhi shi). The emphasis is still on addressing excess, but we see the inclusion of spleen-qi tonification herbs.

With mild liver stagnation with deficiency of spleen qi but without stagnation of stomach qi, one can use Xiao Chai Hu Tang.14 Here, we would see slight wiriness on the left guan-middle position, no wiriness of the right guan-middle position (stomach), and weakness in the deep right guan-middle position (spleen).

In pure deficiency, the pulses are uniformly weak, and the history is one of chronically poor digestion. Here we find deficiency of spleen qi, usually without dampness. These patients tend to be thin and weak, with very poor appetite and energy. I often see it with strict vegetarian patients. By avoiding adequate protein, their hydrochloric acid secretion gradually diminishes and it becomes difficult to digest any food. It is unlikely that one can bring a quick turnaround with these patients. I usually supplement herbal medicine with three to six capsules of hydrochloric acid per meal so they can begin to digest their food. Rehabilitation of the spleen and stomach qi, however, is not accomplished by HCL supplementation, and herbal medicine becomes very important. I rely on either Xiang Sha Liu Jun Zi Tang, or if they are too weak, Si Jun Zi Tang or Liu Jun Zi Tang.15

Lower Burner. If liver stagnation of qi and blood primarily affects the lower burner, there is usually a gynecological complaint: premenstrual syndrome, dysmenorrhea, irregular periods or infertility. For each case, we can often distinguish three stages: ovulation to menstruation, menstruation, and postmenses. Pursue treatment for three to four months.

For ovulation to menses, determine the degree of liver stagnation. For mild stagnation, use Chai Hu Shu Gan Tang, but most cases will respond best to Jia Wei Xiao Yao San.16 This variation of Xiao Yao San  adds zhi zi (Fructus gardenia jasminoides) and mu dan pi (Radix cortex moutan) to help cool the liver.17 Pre-existing liver stagnation will worsen between ovulation and the period due to a natural increase in temperature, and Jia Wei Xiao Yao San is excellent for treating liver stagnation during this time. It is the medicine of choice in premenstrual syndrome.

If menstrual cramps present before or during the period, several formulas are effective if given during the attack. The classical prescription is Shao Fu Zhu Yu Tan, which breaks blood stasis while warming the uterus.18 The modern patent medicine Tong Jing Wan is also effective.19

For postmenses excess-deficiency combinations, use Xiao Yan San or Tao Hong Si Wu Tang, which tonify the blood while moving liver qi and blood.20 You will sense a slight excess to the superficial pulse in the wood position (left guan-middle). In frank blood deficiency without excess, many women in China self-medicate with the patent medicine Wu Ji Bai Feng Wan between menses and ovulation.21


  1. Jing-Yue's Complete Writings.
  2. Injury (By) Cold, Discussion.
  3. Many recent graduates often treat insomnia as a heart-shen disturbance, which has a deficiency root. I have found that insomnia, especially with menstrual disorders or peri-menopausal or menopausal disorders, are best treated as liver excess patterns.
  4. Injury (By) Cold, Discussion.
  5. I would like to offer my clinical experience on tongue diagnosis. While all the textbook information is accurate concerning coats, colors, shapes, etc., I feel that the tongue offers no helpful information 85 percent of the time. Diagnosis is more often dependent on pulses, clinical symptoms and history.
  6. Medical Formulas Collected (and) Explained.
  7. The modern patent medicine is not to be confused with a classical formula of the same name recorded in Thousand Diseases Return (To) Spring. Although four herbs from the original nine-herb formula are found in the modern Shu Gan Wan, the original formula was used for strong liver stagnation with heat.
  8. This formula consists xiang fu (Rhizoma cyperi rotundi), bai shao (Radix paeonia lactiflora), qing pi (Pericarpium citri reticulatae viride), yan hu suo (Tuber corydalis yanhusuo), chai hu (Radix bupleurum) and jiang huang (Rhizoma curcumae longae).
  9. This formula consists of zhi ke (Fructus citrus aurantium), fo shou (Fructus citri sarcodactylis), bai dou kou (Fructus amomi rotundi), chen xiang (Lignum aquilaria), tan xiang (Lignum santali albi), hou po (Cortex magnoliae officinalis), sha ren (Fructus amomi), chen pi (Pericarpium citrus reticulata), xiang yuan (Fructus citri medicae seu wilsonii) and mu xiang (Radix aucklandia).
  10. Dan-Xi's Essential Teachings.
  11. Fratkin J. Chinese Herbal Patent Medicine. The Clinical Desk Reference. Shya Publications, 2001.
  12. Thousand Diseases Return (To) Spring.
  13. Ancient (and) Modern Famous Doctors' Formulas, Discussion.
  14. Injury (By) Cold, Discussion.
  15. Si Jun Zi Tang and Liu Jun Zi Tang are both recorded in Heavenly Peace Benefit (the) People Harmonious Medicines Office of Formulas.
  16. Internal (Medicine) Department Summary. Also attributed to Pattern Treatment Standards.
  17. Heavenly Peace Benefit (the) People Harmonious Medicines Office of Formulas.
  18. Physicians Circle Correction (of) Errors.
  19. Fratkin, pp. 547-50.
  20. Medical Ramparts Supreme Commanders. Also attributed to Medical Tradition's Golden Mirror.
  21. Fratkin, pp. 561-5.

Click here for more information about Jake Paul Fratkin, OMD, LAc.


To report inappropriate ads, click here.