六味小柴胡汤治多年顽咳体会

  Acupuncture can help
 

首页
      Home page
Millwoods Acupuncture Center
102, 2603 Hewes Way
Edmonton AB,   Canada

Phone: (780) 466-8683
www.acupuncture123.ca





























 

 

六味小柴胡汤治多年顽咳体会 

Experience in the use of Liuwei Xiao Chaihu Tang for the treatment of obstinate cough

 

熊兴江 中国中医科学院广安门医院

Dr. Xing-jiang Xiong  (Guang An Men Hospital, Beijing, China)

 

六味小柴胡汤由柴胡、黄芩、半夏、甘草、干姜、五味子组成,出自《伤寒论》第96条小柴胡汤方后加减法,因其为小柴胡汤的加减方,且由六味药物组成,故称之为“六味小柴胡汤”。笔者用之治疗外感发热、急慢性支气管炎等疾病,如果方证合拍,止咳退烧疗效迅速,且屡试不爽。

The herbal formula Liuwei[1] Xiao[2] Chaihu Tang[3] consists of Chaihu, Huangqin, Banxia, Gancao, dried ginger and Wuweizi. It comes from the introduction for the modification of the herbal formula Xiao Chaihu Tang in the  96th paragraph in the book <<Shang Han Lun>>. For it is the modified formula of the Xiao Chaihu Tang, and it consists of only six herb ingredients, it is called “Liu Wei Xiao Chaihu Tang”. I have been using this formula for the treatment of common cold, acute and chronic bronchitis, and so on. If the formula is used for a matched condition, it works very fast to stop cough and reduce the fever. This has been proven again and again.

我们发现病邪进退于少阳之际往往会出现三种情况,一为单纯少阳类型,病邪滞留于少阳不解,临床必须运用和解少阳之法;二为少阳阳明同病类型,少阳证呈现“热化”趋势,可能这与素体阳热偏亢有关,或传阳明而成少阳阳明合病,或病邪从阳明传至少阳,如外感疾病少阳证中复见口干口渴欲饮冷、高烧面赤而不恶寒,则往往是合并有石膏药证,复见咳嗽痰黄黏,则往往合并桔梗、薏苡仁药证;三为少阳太阴同病类型,少阳证呈现“寒化”趋势,可能与素体脾胃虚弱有关,这往往为本方所主治。

We found that, when a disease is in the Shaoyang phase, there could have three different outcomes for the further development of the disease: first, pure Shaoyang phase. The disease sticks in the Shaoyang phase. In clinic, the Shaoyang-calming therapy (Shaoyang-harmanizing therapy) should be used. Second, the co-exist of the Shaoyang and the Yangming phases. The Shaoyang condition tends to become “hotness-developing”. This might be due to the body is in Yang overwhelming condition before the diseased, or due to the Shaoyang phase further develops into the Yangming phase; or due to the disease develops from the Yangming back into the Shaoyang phase. For example, in the external disease, the disease is in Shaoyang phase, but the person starts to have dry mouth and thirsty with desire to drink cold water, have fever with red color in face and has no cold-dislike feeling. This is the condition of Xiao Chaihu Tang plus Shigao. If the person has cough with yellow and sticky phlegm, the herb Jiegen and Yiyiren should be used. The third, the Shaoyang phase co-exists with the Taiyin phase. The Shaoyang condition tends to have “cold-developing” phenomenon, which might be due to the person usually is weak in the Spleen-stomach system.

小柴胡汤证的典型表现有口苦,咽干,目眩,往来寒热,胸胁苦满,默默不欲饮食,心烦喜呕,头痛,腹痛,脉弦等,根据方证对应中的药证原则不难发现,本方证实质就是小柴胡汤证复合了干姜、五味子药证,即病中复见“寒咳”、“寒泻”症状,如干咳,或咳白黏痰,咳嗽经久不愈,大便稀溏,或腹泻。

The typical conditions for the use of the Xiao Chaihu Tang is bitter taste in mouth, dry throat, dizziness in eyes, cold-hot shift feeling, annoying bloating feeling in the chest and in the upper side of the belly, silent and no appetite, annoyed and tends to have vomit, headache, belly pain, and string pulse, etc. Based on the principle in the use of the herb formula, that the herb formula should match the body condition, it is not hard to find that the herbal condition for the use of this Liuwei Xiao Chaihu Tang is the condition to use the Xiao Chaihu Tang plus the condition to use the herb dried ginger and Wuweizi. This means that, the herbal formula should be used if the patient has some of the conditions indicating to use the Xiao Chaihu Tang, together with the conditions to use the dried ginger and Wuweizi, such as “cold cough” and “cold diarrhea”, dry cough, or white and sticky phlegm, or obstinate cough for long time, diarrhea (loss stool).

兹举笔者应用该方治疗多年顽咳医案一则。

Here is a case example for the treatment of a chronic obstinate cough

王某,女,33岁。20091127日就诊。

Mrs. Wang, female,33 years of old. She visited the clinic on Nov. 27, 2009.

患者自诉从1岁开始咳嗽,每年无明显诱因于入冬后咳嗽,以干咳为主,或咳出少量白黏痰,受凉、油烟刺激、劳累或大声说话后加重,加重时必须连续咳嗽十几分钟后方能缓解,冬季天天如此,入春则止,一切如常人。其余季节如逢剧烈的情绪刺激,咳嗽基本与冬季相同。患者前往某医院诊治,诊断为“慢性支气管炎”,服肃肺止咳化痰中药(桔梗、杏仁、半夏等)及化痰止咳等西药多年,未见明显效果。半月前开始咳嗽,

The patient started to cough when she was one year old. Every year in winter, she could have cough without any triggering reasons. The cough is mostly a no-phlegm cough, or spit only little white and sticky phlegm. The cough would become worse when she exposed to cold, oily smoke, physically exhausted, or loudly speaking. In this case, she needed to have continuous cough for up to tens of minutes to stop. Every winter was the same and the symptoms stop once the spring comes. Then she had no any symptom. In spring, summer and fall, the cough would come again with strong emotional stimulation, and the symptoms would be the same as in winter. Her condition has been diagnosed as “Chronic bronchitis”. She was given herbal therapy (the use of Jiegen, Xingren and Banxia, etc.), as well as western medicine, for many years without clear improvement. Half month ago, she started to have the cough again.

刻下症见:干咳,咽痒或嗳气后引发,油烟刺激、大声说话后加重,一刻钟后方能自行缓解;脾气急躁,喋喋不休;不容易出汗,面部痤疮散在多发,色暗红,食欲、睡眠均好,小便略黄,大便正常,舌体瘦小,舌苔薄少,脉细弱数。查:血压145/90mmHg,双肺呼吸音粗,心率105/分钟,节律齐。西医诊断:慢性支气管炎。中医诊断:咳嗽。证属肝气不畅,肺气不降。治以疏肝清热,温肺散寒止咳,予六味小柴胡汤原方,处方:柴胡12克,黄芩10克,半夏12克,干姜6克,五味子6克,生甘草6克。5剂,水煎服,日1剂。

Her conditions when she visited were: she had dry cough, which was triggered by itch in throat or by belch, and which was worse after exposure to oily-smoke or loud speaking. The continuous cough needed about 15 minutes to stop. She had hot temple and had continuous talk. It was not easy for her to have sweat. She had multiple acne on face, which were dark red in color. Her appetite and sleep were normal. The urine was little yellow in color. Bowel movement was normal. Her tongue was thin and small in shape. The tongue cover was thin and little. The pulse was thin, weak and frequent. Blood pressure was 145/90 mmHg. The breath sound on the lung was harsh. The heart beat was 105 times per minute. The rhythm was normal. The diagnosis was chronic bronchitis by western medicine and cough by the Chinese medicine with Liver Qi sluggish and Lung Qi not descending. The herbal therapy was given to dredge the Liver, to clear the hotness, to warm the Lung and to stop the cough. She was given the Liuwei Xiao Chaihu Tang. The herbal ingredients were: Chaihu 12 g, Guangqin 10 g, Banxia 12 g, Dried ginger, Wuweizi 6 g, Gancao 6 g. The herbs were cooked in water. Five doses were prescribed, one dose every day.  

123日二诊:患者服用上方3剂后咳嗽明显好转,咽痒消失,偶于大声说话后出现干咳,持续时间极短即能自行缓解,再进2剂后诸症消失。换方治疗面部痤疮,并嘱咐患者自备数剂六味小柴胡汤于家中,咽痒即服用。随访至今未复发。

The second visit on the Dec. 3. After three days of the herbal therapy, her cough was much improved. The itch feeling in throat disappeared. She could have dry cough again occasionally after loud speaking but it lasted a very short time before stop. After additional two doses, all the symptoms subsided. The herbal therapy was changed to treat the facial acne. She was also asked to keep some amount of the Liuwei Xiao Chaihu Tang at home in case she has cough again. Following up so far, she had no any recurrence.

按:该患者咽痒或油烟刺激后干咳,呈现出“往来咳嗽”现象,如若诊查不出明显的痰饮、表证、阳虚等指征,就可以看做是少阳证“往来寒热”的一种延伸,这是柴胡药证;柴胡证典型的表现是神情默默,所以一般认为情绪低落,食欲不振,性格偏内向等肝气郁结症状是柴胡证、柴胡体质的识别关键,但是我们也发现临床不尽如此,柴胡证也可以表现为情绪亢奋,脾气急躁,喋喋不休,焦虑紧张,甚至恐惧惊悸等肝郁化火症状。该患者脾气急躁,喋喋不休,容易兴奋激动,容易血压波动、心率加快,情绪波动后咳嗽等也是柴胡、黄芩药证;冬季咳嗽,春季自行缓解是典型的“寒咳”,是五味子、干姜药证;嗳气后引发咳嗽,这是胃气上逆,是半夏药证。药后咳嗽明显好转,提示方证对应。

Comment: This patient has cough after itch feeling in throat or exposure to oily smoke. The cough comes and goes.  If there is no clear evidence for phlegm condition, for body surface condition or Yang deficiency, it can be regarded as an expanded concept of “cold-hotness shift that comes and goes”, which is one of the key condition to diagnose Shaoyang phase. This is the indication for use of herb Chaihu. One of the typical clinic conditions to diagnose Chaihu condition is the silent and no-desire emotion. Therefore, it is generally believed that it is the key point to diagnose the Chaihu condition, or a Chaihu body constitution, is when the patient shows depression, low appetite, introvert personality, etc. all of which belong to Chaihu condition or Chaihu body constitution. However, we found that, in clinic, the Chaihu condition is not always showing as such. The Chaihu condition can also show as hyperactive spirit, hot temple, no-end talk, anxiety, even scared or phobia feeling, such Liver Fire developed from Liver Qi sluggish. The patient in this case has hot temple, tends to talk too much, easy to get anxiety and rising spirit, easy to have blood pressure fluttered and heart beat speeds up, and has more and worse cough after emotional stimulation, all of which indicate the Chaihu and Huangqin condition too. It is typical “cold cough” when the cough becomes worse in winter but less in spring, which is the herbal indication for the use of Wuweizi and dried ginger. That the cough comes after belching, which suggests the Stomach Qi reversely rushing up, is the indication for Banxia. That after the use of the herbal therapy with Liuwei Xiao Chaihu Tang, the cough subsided dramatically proves the correct and the match between the herbal therapy and the body condition.

值得注意的是,急性病注重辨证,而慢性病则要注重辨体质,因此疾病往往有“病”和“体质”两个层面。史欣德教授认为慢性疾病大多为在某种体质类型的基础上复合夹杂了某种疾病。舌体瘦小,舌苔薄少,脉细弱数,满脸痤疮等均是典型的肝阴不足体质表现,究其原因,不外乎失血伤阴和五志过激化火伤阴这两方面。患者月经正常,未见明显失血病史,因此我们推测肝阴不足可能与脾气急躁有关。该患者的疾病实质为肝阴不足的体质夹杂了六味小柴胡汤证,治疗上应当标本同治。需要说明的是,虽然有“柴胡劫肝阴”之说,但有是证用是方,本案用六味小柴胡汤治病治标,且中病即止,咳嗽治好后随即易方治本调理体质,对患者并不会造成损害。

It is worthwhile to note that it is more emphasized on the condition or syndrome diagnosis for an acute disease, and on the body constitution diagnosis for a chronic disease. Therefore, the disease usually has both the “disease/syndrome” and the “body constitution” aspects. Dr. Xing-de Shi believed that, a chronic disease usually means under some kinds of body constitutions, the patient has some diseases. That the tongue is small and thin, that the tongue cover is thin, and that the pulse is thin, weak and frequent, and that there are many acne on face, all are the typical condition for Liver Yin deficiency. The reason for the Liver Yin deficiency might be due to blood loss that exhaust the Yin, or to the exhaustion of the Yin by the Fire that develops from the overwhelming of emotional stimulations. For the patient in this case, she has normal menstruation, and no history of blood loss. It is therefore deduced that her Liver Yin deficiency might be due to her hot temple. The truth for her disease is the Liuwei Xiao Chaihu Tang condition and the Liver Yin deficiency. It should be pointed out that, though there is an opinion that “Chaihu exhausts Liver Yin”, the Chaihu still needs to be used if there is indication to use it in the disease. In this case, the Liuwei Xiao Chaihu Tang was stopped after the cessation of the disease. The herbal formula was changed after the stop of the cough to correct the body constitution. Therefore, there was no worry for the hurt to the patient.



[1] Liuwei: six herbal ingredients.

[2] Xiao: small.

[3] Tang: herbal extract.