an gong niu huang wan (安宫牛黃丸)

The palace is a compound in which the emperor resides. It is used here as a metaphor for the Pericardium, which surrounds and shields the sovereign organ (the Heart) in the same manner as a palace surrounds and protects the emperor. This formula clears heat from the Pericardium, which calms the Heart’s spirit.

Method of Preparation
Grind the ingredients into a powder and form into pills with honey. The pills should be 3g in weight and are traditionally coated with gold leaf, although this is not the modern practice. Take one 3g pill2-3 times daily (depending on the severity of the condition and the strength of the patient) with warm water. The source text advises that children take one-half pill at a time, which has been refined at present to one-quarter pill for children under 3 and one-half pill for those 4-6 years of age. If the patient is comatose, the formula may be administered via a nasogastric tube.
Note that the original text specifies 30g of Rhinocerotis Cornu (xi jiao), which is no longer used, primarily due to the endangered status of the rhinoceros. At present, due to their heavy metal content, neither Cinnabaris (zhu sha) nor Realgar
(xiong huang) should be used.

Actions Clears heat, resolves toxicity, dislodges phlegm, opens
the sensory orifices, and calms the spirit

High fever, irritability and restlessness, delirious speech, impaired consciousness, the sound of phlegm in the throat, a dry mouth, a parched tongue that is red or scarlet, and a rapid pulse. Also for coma due to wind-stroke or childhood convulsions with a similar presentation, and for stiffness of the tongue and frigid extremities.
This is a serious abnormal progression of a warm-febrile disease. The pathogenic heat sinks into the Pericardium and
disturbs the spirit causing high fever, irritability and restlessness, delirious speech, impaired consciousness or coma. As noted in Chapter 71 of Divine Pivot, “All the pathogenic influences that [appear to be] in the Heart are in the collateral of the Heart’s wrap [i.e., the Pericardium]:’ The blazing heat in the interior scorches and condenses the fluids, which leads not only to a red or scarlet tongue and a rapid pulse, but also to phlegm that can be heard in the throat, veils the sensory orifices, and impairs the consciousness. As stated by Zhang Bing-Cheng in Convenient Reader of Established Formulas, “Presentations of warm pathogens sinking internally must include sticky, greasy, filthy turbidity lingering in the midst of the diaphragm:’ This turbid phlegm aggravates the impaired consciousness due to heat. This is one type of serious phlegm-heat and can lead to a loss of consciousness.

This pattern may also be viewed as a hot-type closed disorder due to phlegm-heat obstructing the orifices of the Heart. This often occurs in cases of childhood convulsions or coma due to wind-stroke. Because the Heart ‘opens’ through the tongue, the tongue may become stiff, making speech difficult.
The internal obstruction from pathogenic heat sinking deep into the body may confine the yang qi in the interior. When the yang qi is unable to reach the extremities, they become very cold. This combination of impaired consciousness, stiff tongue, and very cold extremities (distal to the elbow) is called ‘limb collapse’ (肢厥 zhi jue).

Analysis of Formula
This formula is designed to clear heat and resolve toxicity in the Pericardium. Its focus is on aromatically opening the orifices, while secondarily dislodging phlegm and calming the spirit. This wiU result in clearing of the heat toxin, opening of the sensory orifices, transforming of the turbid phlegm, and calming of the spirit.

One of the chief ingredients, bitter, cool, and aromatic Bovis Calculus (niu huang), is very effective in clearing heat from both the Heart and Liver channels. Its aromatic properties vent heat to the exterior by way of the collaterals of the Pericardium. In addition, this ingredient resolves toxicity and dislodges phlegm to open the sensory orifices, extinguish wind, and stop the spasms, tremors, or convulsions. It thereby addresses all the major aspects of this condition. The second chief ingredient, Moschus (she xiang), aromatically opens up the orifices and revives the spirit as it penetrates all twelve channels of the body. As noted in Comprehensive Outline of the Materia Medica, it “runs and scurries everywhere as it is able to unblock all the orifices that have difficulties and open up clogs and snags in the channels and collaterals.” Its strong aromatic nature is essential in treating a disorder in which the sensory orifices are veiled by phlegm. The two chief ingredients are a strong combination for clearing the Heart and opening up the orifices.

The deputies focus on clearing heat. Salty, cold Bubali Cornu (shui niu jiao) enters the nutritive and blood levels and plays an important role in clearing fire and heat from the Heart, Liver, and Stomach channels. It clears heat from the Heart, calms the spirit, cools the blood, and resolves toxicity. Its cool, aromatic properties quickly vent pathogenic heat from the Pericardium. Coptidis Rhizoma (huang lian), which focuses on Heart fire, Scutellariae Radix (huang qfn), which focuses on clearing heat from the Gallbladder and Lungs, and Gardeniae Fructus (zhf zf), which clears and disperses heat from constraint in the Heart and Triple Burner, all work together to conduct the heat downward, assisting Bovis Calculus (niu huang) in clearing and draining heat toxin from the Pericardium.

The other set of deputies help Moschus (she xiang) in aromatically clearing away turbidity. Acrid and bitter Borneolum (bing pian) is highly aromatic, scurries everywhere, and is good at unblocking the orifices. Acrid and bitter Curcumae Radix (yu jin) opens up and directs downward; its aromatic nature allows it to disseminate and thrust out as a means of moving the qi and releasing areas of constraint. These deputies unblock the orifices and disperse the heat from constraint, thereby helping the chief ingredients vent heat through the co !laterals of the Pericardium.

There are three assistants. Margarita (zhen zhu) clears heat from both the Heart and Liver channels and is effective at sedating and moving phlegm downward. The other two assistants are generally considered obsolete. Realgar (xiong huang) dislodges phlegm and resolves toxicity, thus helping to open the sensory orifices by draining the turbid phlegm. Cinnabaris (zhu sha) clears heat from the Heart. Honey serves as an envoy by harmonizing the Stomach and regulating the middle burner. The gold leaf coating on the pills also serves as an envoy by calming the spirit.

The general effect of this formula is concisely described in the source text as “leading the pathogenic fire to be dispersed by way of the dispersing [action] of all the aromatic.”

Cautions and Contraindications
Contraindicated during pregnancy. This formula should only be used for hot-type closed disorders. Because it is extremely cold and aromatic, its use should be discontinued once the desired effect occurs and should not be taken long-term.

Both phlegm and heat are very strong in these patterns. In such cases, unless the turbid phlegm is eliminated, it will be difficult to clear the heat. It is therefore common to combine ingredients for clearing heat with others that dislodge and drain turbid phlegm.

The author of this formula, Wu Ju-Tong, succinctly summarized its actions: “The aromatic [ingredients] of this formula transform turbidity and benefit all the orifices; the salty and cold [ingredients] protect the Kidney water and calm the body of the Heart; the bitter and cold [ingredients] unblock the fire in the yang organs and drain the Heart:’ Note that, as with many of his other formulas, Wu’s composition of this formula was heavily influenced by the clinical experiences and work of Ye Tian-Shi.

Wu also noted that this formula could be used for heat causing other problems, including ‘flying corpse’ (fei shi), which refers to people becoming seriously ill so quickly that it appears that some pathogen has flown at them, spasms that lead to a loss of consciousness in adults and children, any of the five types of epilepsy, as well as noxious attack (e zhong). This last condition was earlier defined in Indispensable Tools for Pattern Treatment:
Sudden, frigidly cold hands and feet, goose pimples, cyanotic face and head, and disturbed mental state from suddenly being accosted by an abnormal qi. There may be jumbled speech and crazy talk, locked jaw, or even dizziness with falling down such that the person does not recognize other people.

It is this note from Wu that provided the basis for later practitioners to expand the use of this formula to include certain types of insanity, with the appropriate signs and symptoms.

Contemporary Usage
This is the model formula for clearing heat and opening the orifices in acute cases. The main clinical markers are impaired consciousness, delirious speech, high fever, irritability and restlessness, a red or scarlet tongue, and a rapid pulse. It is widely used in China today, to the point where it has been developed into a liquid that can be given intravenously. The commercial formulations use artificial forms of the very expensive medicinals such as Moschus (she xiang), and most do not include gold leaf or the obsolete medicinals Cinnabaris (zhu sha) and Realgar (xiong huang). Instead, they may add substitutes such as Haliotidis Concha (shi jue ming). It is often given to patients whose conditions are deteriorating, but who have not yet become comatose or delirious.

Biomedical Indications
With the appropriate presentation, this formula may be used to treat a wide variety of biomedically-defined disorders.
These can be divided into the following groups:
• Acute infections of the central nervous system such as viral encephalitis (including type B) and viral meningitis
• Other central nervous system disorders such as cerebrovascular accidents, schizophrenia, epilepsy, or hepatic encephalopathy
• Acute infections such as upper respiratory tract diseases, tonsillitis, sinusitis, otitis media, pneumonia, asthma, acute icteric hepatitis, acute pancreatitis, toxic dysentery, acute neprhitis, and epidemic hemorrhagic fevers.

This formula has also been used in the treatment of hepatic cancer, uremia, leukemia, septicemia, and Kawasaki disease.

Altemate names
Cattle Gallstone Pill (niu huang wan) in Systematic Differentiation of Warm Pathogen Diseases; Newly-Revised Cattle Gallstone Pill to Clear the Heart (xln dlng niu huang qlng xln wan) in Revised and Expanded Popular Guide to the Discussion of Cold Damage; Pill for Calming the Palace (an gong wan) in National Collection of TCM Patent Formulas

• For patients with a deficient pulse, take with a decoction of Ginseng Radix (ren shen).
• For patients with an excessive pulse, take with a decoction of Lonicerae Flos (jin yin hua) and Menthae haplocalycis Herba (bo he).
• For patients with high fevers, take with Purple Snow Special Pill (zi xue dan).