Zhi Zhu Tang (Atractylodes and Immature Bitter Orange Decoction) zhǐ zhú tāng · 枳术汤

Safety. Zhi Zhu Tang is recorded in Jingui Yaolüe, in the chapter on water qi, where the indication is given in one of the most concrete images in the classical literature: a hardness below the heart, as large as a plate, with an edge like a turned plate, made by water and rheum. Two herbs — zhi shi in the larger proportion, bai zhu in the smaller. This is the same pair as Zhi Zhu Wan with the weights reversed, and the reversal is the whole point: here the moving herb outweighs the supplementing one, and the preparation is a decoction, taken over days rather than weeks. Two formulas, the same two herbs, opposite ratios and opposite intent. What a modern reader most needs is a list of what a firm mass in the upper abdomen can actually be. Hepatomegaly and splenomegaly. Gastric distension or retention. A pancreatic pseudocyst or tumour. A colonic or ovarian mass. And, most importantly, an abdominal aortic aneurysm: a pulsatile mass in the middle or upper abdomen in an older person with a history of smoking or hypertension should be assumed to be vascular until imaging says otherwise. It should not be pressed, needled, massaged or manipulated, and rupture presents as sudden severe abdominal or back pain with hypotension. A mass with jaundice, weight loss or anaemia needs imaging and endoscopy rather than a formula. Classical texts were written before any of this was available, and a classical indication is not a substitute for characterising a mass. Safety. This is a formula whose intent is to move and disperse, and it is not appropriate where the cause of abdominal pain has not been established. The cautions recorded for zhi shi apply here: it contains p-synephrine, the sympathomimetic amine for which bitter orange extracts have attracted regulatory attention over cardiovascular events. Zhi shi and zhi qiao are not interchangeable, and bai zhu and cang zhu are not interchangeable. Herbs of this family are traditionally cautioned in pregnancy. This library does not claim the formula resolves a mass or treats any specific disease.