Many of the presentations associated with the classic formulas from the Shang Han Lun and other classic texts can be understood in the context of Zang Fu, 8 principle, 6 pathogen and Qi, Blood, and body fluid theory. To look at a just a few of many examples:

1. Ma Huang Tang (Ephedra Decoction) treats a presentation that can be called excess cold damage on the exterior or excess cold fettering the Lungs.
2. Si Ni Tang (Frigid Extremities Decoction) treats a presentation that can be called Kidney Yang deficiency.
3. Huang Lian E Jiao Tang (Coptis and Asshide Gelatin Decoction) ) treats a presentation that can be called Kidney and Heart Yin deficiency with excess heat.
4. Bai Hu Tang (White Tiger Decoctions) treats a presentation that can be called excess heat in the Lung and Stomach.

Though there are many other ways to think about and use these classic formulas, most of them can be thought about and analyzed in the context of standard TCM.

However, there are some formula presentations from the classic Shang Han and Wen Bing texts that do not fall easily into TCM patterns. Because of this, some of these formulas are hardly used at all, are misunderstood and therefore misused, or are used merely symptomatically. At any rate, they are not used to the full extent of their potential if we only understand them in the context of standard TCM.

As an introduction to the course I will be teaching at the 2008 Pacific Symposium, I will briefly write here about some formulas that fall into the category of "hard to understand the presentation of it in a TCM context". These formulas will come from both the Shang Han and Wen Bing texts. I'll also discuss a central reason why these presentations cannot be understood through our standard means and hint at the clinical possibilities that appear when we open up our thinking about them. The courses that follow from this article will give a much more in-depth understanding of these formulas, what they all have in common, how to diagnostically differentiate them, as well as their wide range of clinical relevance. The course will include translations from a variety of sources as well as illustrative case histories from my own practice.

The following formulas all have something in common that is related to the fact that they fall into the "hard to understand the presentation of it in a TCM context" category.

From the Shang Han Lun Xiao Chai Hu Tang (Minor Bupleurum Decoction) Ban Xia Xie Xin Tang (Pinellia Heart-Draining Decoction) Sheng Jiang Xie Xin Tang (Fresh Ginger Heart-Draining Decoction) Gan Cao Xie Xin Tang (Licorice\ Heart-Draining Decoction)

From the Wen Bing school Hao Qin Qing Dan Tang (Artemisia Annua and Scutellaria Decoction to Clear the Gallbladder) Lei Shi Xuan Tou Mo Yuan Fa (Lei's Decoction to Disseminate and Vent the Membrane Source) Da Yuan Yin(Reach the Membrane Source Decoction) and Wen Dan Tang (Warm the Gallbladder Decoction) Wen Dan Tang, Warm the Gallbladder Decoction.

The 3 principle commonalities shared between the presentations of these formulas can be summarized as follows:

1. All of the presentations associated with these formulas include symptoms that indicate disruption of the free ascending and descending movement in the middle warmer.
2. With the exception of the three Xie Xin Tangs mentioned here, all the presentations for these formulas include the symptoms of alternating fever and chills.
3. The location of the disruption that indicates the use of these formulas\ is described in the following ways. Clinically, it is useful to consider the above six locations to be in a certain sense, synonymous.
   1. The Shao Yang
   2. Half Interior and Half Exterior
   3. The Pivot
   4. The Triple Burner and Gallbladder
   5. The Mo Yuan or Membrane Source
   6. The Middle Burner/ epigastric area

The connection between these locations is not a new idea. Many scholar-doctors over the centuries have written about them synonymously. For example, The Basic Questions (su wen) says "The Shao Yao is the Pivot" The Systemic Differentiation of Damp-Heat (She re tiao bian) says "The membrane source is located between the Stomach and the muscle layer. It reaches the muscles externally and the Stomach internally, and is the gate of the Triple Burner.It is in the halfexterior and half-interior part of the body."

"Both the Gallbladder and the Triple Burner belong to the lesser Yang and impairment of Gallbladder free coursing and/or impairment of the Triple Burner's regulation of the waterways are often described in terms of inhibition of the 'pivot mechanism'".

You Zaijing writes "Shao Yang resides between the external and internal. It is the place of the Huang membrane, which is between the heart and diaphragm. Externally it does not reach the skin and internally it does not reach the Zang Fu"

Admittedly, for English speaking scholars and Chinese scholars alike, some of these definitions are enigmatic and have been debated and mulled over for centuries. My interest in looking at them as synonymous is to observe the clinical insight and clinical results we can get if we look at it this way. I certainly don't mean to imply that this is the only correct way to consider these terms. In addition, the definitions of some of these terms, such as Mo Yuan, Huang Membrane, and even the pivot, are vague at best and have been hotly debated.

For the sake of this short article though, in my own words, I will introduce how I have come to classify these formula presentations in a similar category. Taking a broad view of physiology and pathology, there is the metaphor of the see-saw: If we say that healthy physiology is a balance between the two sides of the see-saw and that pathology is an imbalance between the two sides, this means that when there is an imbalance, the see-saw does not move properly or in a balanced way and that this is because the sides are not balanced between each other. With the diagnosis we come to and the formulas we use, we strive to identify and treat the imbalance so that the see-saw can move evenly and smoothly. We determine where and what we need to add and subtract. I would call the ability to diagnose such imbalances the same as being able to diagnose in a standard TCM manner.

Continuing with the metaphor of the see-saw, there is another type of problem that can disrupt balanced movement in addition to differential problems between the two sides. If there is a problem with the fulcrum (also known as the pivot, middle or hinge) itself, the movement of the see-saw will also be disrupted. It may appear as if there is an imbalance on one side or the other if we simply observe the way the two sides are moving. However, it may actually be a problem with the pivot. Any attempt to diagnose the\ imbalance through even the best TCM diagnosis will be inaccurate and give poor results because the location of the disruption is not being addressed. It becomes clear why pivot pathology is difficult to place in a standard TCM diagnostic frame.

I have listed eight prescriptions above. Though this is not an exhaustive list of the prescriptions for addressing issues with the pivot, it does provide us with a substantial beginning for understanding the nature of pivot physiology and pathology, for differentiating the possible ways the pivot can be disrupted, and for learning how to recognize and differentiate appropriate treatment of the pivot.

Since being able to identify and differentiate pivot pathology, I've observed many interesting and inspiring clinical outcomes. Symptoms that I would have or did diagnose through Zang Fu, 8 parameter, Qi, blood and body fluid, and 6 pathogen paradigms, unravel when the pivot is correctly identified as the issue and is properly addressed. Some examples of pathology I've successfully treated with this method are:

• Allergic asthma with chronic malaise and fatigue
• Food allergies with itchy groin and chronic hip pain
• Dysmenorrhea
• Insomnia with chronic (20 year) digestive disturbance
• Menopausal syndrome
• PMS followed by monthly post-mentrual flu.

There are several steps required in identifying a pivot difficulty. The first is to identify that it is a pivot difficulty. The second is to identify the nature of the difficulty and the appropriate formula presentation. In other words, the second step is to identify the correct pivot formula to use. These steps can be talked about separately, but in the clinical reality they are not really so separate. In regard to this, there are several\ points to make.

1. Alternating fever and chills is a hallmark sign of pivot pathology.
2. If there is no alternating fever and chills, abdominal diagnosis and certain key symptom presentations can also reveal pivot pathology.
3. Outside of the above manifestations, signs and symptoms alone cannot reveal pivot pathology.
4. With the presence of alternating fever and chills, tongue diagnosis and abdominal diagnosis are necessary to further differentiate the nature of the pivot pathology and hence the appropriate formula.
5. The concept of alternating fever and chills can be expanded:

   a. "Within the phrase 'alternating cold and heat', there is the phrase 'alternating' . This in itself has a special meaning.it can refer to the protracted and slowly changing nature of an illness. It can refer to a rhythmic quality. This could be daily rhythms, weekly rhythms, or monthly rhythms. The daily rhythm issues may be, for example, insomnia or being up late with no feeling of being sleepy. These days, we see the Monday morning syndrome, which is an example of the weekly rhythm. The monthly rhythm may manifest as premenstrual syndrome or mammary hyperplasia. Some will have allergic bronchitis, allergic sinusitis or pollen allergy, which is a seasonal rhythm. There may not be a clear rhythm in that it may sometimes be there and sometimes not be there. It may be difficult to get a handle on, for example, with neurological disorders such as epilepsy or allergic type illness".

6. Another important idea in differentiating pivot pathology from a Shang Han Lun perspective in contrast to a Wen Bing perspective is the presence or absence of an actual pathogen. Again, this is a hotly debated topic, which to me means that no one really knows for sure. However, for the purposes of this article and the courses that follow, I'll pick and attempt to articulate the perspective that, in this context, makes sense to me and that I have found to be clinically useful. In terms of the formulas listed above, the ones from the Shang Han Lun are, Xiao Chai Hu Tang, Ban Xia Xie Xin Tang, Sheng Jiang Xie Xin Tang, and Gan Cao Xie Xin Tang. These formulas treat a presentation in which there is no pathogen to be removed. This means there is no pathogen in the Shao Yang or Epigastric area. Rather, the pivotal movement has been damaged or disrupted. Any pathogens present are a result of the disruption and not the cause of it. Formulas to treat the pathogenic accumulations will unfailingly give poor , if not contradictory results. On the other hand, the later formulas that are more from the Wen Bing school, are Hao Qin Qing Dan Tang (Artemisia Annua and Scutellaria Decoction to Clear the Gallbladder), Lei Shi Xuan Tou Mo Yuan Fa (Lei's Decoction to Disseminate and Vent the Membrane Source), Da Yuan Yin(Reach the Membrane Source Decoction) and Wen Dan Tang (Warm the Gallbladder Decoction). For Wen Bing presentations in general, it could be said that there is a pathogen, that the pathogen is responsible for the disruption and to recover the healthy physiological activity, the pathogen itself must be removed. In summary, there is no pathogen to be removed in the Shang Han pivot presentations and there are pathogens to be removed in the Wen Bing presentations.

My hope in writing this article is to whet the reader's appetite for more in-depth insight into this treatment strategy, as well as to offer a clarifying perspective on some obscure concepts in our field without sacrificing clinical applicability. In the course that follows this paper, we will look more deeply at the physiological and pathological mechanism of the pivot, deconstruct the symptom presentations and formula compositions, demonstrate the abdominal and tongue presentations, and take a look at some case histories. In addition, source material, including case histories, translated by this author will be made available. OM