绍奇谈医( 转自民间中医网 )1

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 绍奇谈医(简略版)

何绍奇 转自民间中医网

(Part I)

 

1. 金匮要略札记

1. Booknotes for book Jin Kui Yao Luo

2.  小青龙汤

2. Xiao Qinglong Tang

3. 半夏泻心汤及其变方

3. Banxia Xiexin Tang and its variations

4. 风湿三方

4. Three herbal formula for the Wind-wetness disease

5.  桂枝加附子汤

5. Guizhi plus Fuzi Tang

6. 桂枝加厚朴杏子汤

6. Guizhi plus Houpu Xingzi Tang

7. 关于理中汤的两种加味

7. The two modifications for formula Li Zhong Tang

8. 小陷胸汤

8. Small Xiexiong Tang

 

 

 

1.  金匮要略札记

1. Booknotes for book Jin Kui Yao Luo

 

(1). 脏坚癖不止  

(1). The organ is as a hard mass.

妇人杂病脉证并治第二十二载: 妇人经水闭不利,脏坚癖不止,中有干血,下白物,矾石丸主之。

In the Chapter 22, various disease in female: it states that, if the woman has disorder in menstruation, and there is hard mass in the belly (in uterus), it means there is dead blood clot in it. There would have white color stuff excreted out. In such case, use the Fanshi pill mostly for the treatment.”

脏坚癖不止,文义不通,传抄之误也,应作:脏坚癖,中有干血,下白物不止。

It should be understood as: “there is hard mass in the uterus, in which there is dead blood clot, and there would be continuous dispel of white color stuff from the uterus.”

 

(2).  人参汤

(2). Renshen Tang

胸痹心痛短气病脉证并治第九载: 胸痹心中痞,留气结在胸,胸满,胁下逆抢心,枳实薤白桂枝汤主之,人参汤亦主之。

In the Chapter 9, the diagnosis and treatment of chest pain, heart pain, and short of breath, it states: “ If there is strong pain in the chest, there is bloating feeling in the heart zone, it means accumulation of bloating Qi in the chest to cause bloating feeling in the chest. The pain starts from the right side of the stomach and expands towards the heart region. In this case, use Zhishi Xiebai Guizhi Tang or use Renshen Tang. 

人参汤方即理中汤,用于此证,不能无疑。心阳虚衰,阴霾充塞,理中汤恐难以胜任。当是伤寒论太阳篇163条之桂枝人参汤 (桂枝四两、炙甘草四两、白术三两、人参三两、干姜三两),用桂枝温通心阳,以人参、甘草益气,白术、干姜健脾温中为继,于理当可通。其错似出在人参汤前遗漏桂枝二字。

The Renshen Tang is also called Lizhong Tang. It is doubt to use it in this condition, in which the Heart Yang Qi is in weakness condition, and the Yin Qi is overwhelming in the chest, and the Lizhong Tang may not be strong enough to solve this condition. It might be the Guizhi Renshen Tang that is introduced in the Chapter 163, in the discussion for the diagnosiss and treatment of Taiyang disease, in the book <<Shang Han Lun>>. The Guizhi Renshen Tang contains Guizhi 4 liang[1], Zhi Gancao 4 liang, Baishu 3 liang, Renshen (ginseng) 3 liang, and dried ginger 3 liang. The Guishi is used to warmly conduct the heart Yang Qi, and the Renshen and Gancao is to nourish the Qi. The Baizhu and dried ginger is to nourish the Spleen, and to warm the middle portion of the body. It therefore matches the need for the disease condition. The mistake might be the miss of the Guizhi in front of the Renshen Tang.

 

(3).  百合病,见于阴者,以阳法救之

(3). For the Baihe disease, if the condition belongs to the Yin aspect, use Yang-nourishing therapy to treat. 

百合病多属阴虚内热,治以百合地黄汤诸方,即见于阳者(阳热症状,如口苦小便赤,脉微数)以阴法(养阴清热)救之,此无疑义。但仲景又说:见于阴者,以阳法救之,是因为世间万事,有常就有变。百合病即以阴虚内热为常,以阳气虚馁为变,故养阴清热为常法,温养阳气为变法。原文未出变法之方,而甘麦大枣汤一方,呼之欲出。

The Baihe disease is commonly in a Yin deficiency and inside hotness condition. It is treated with Baihe Dihuang Tang and such, e.g. if the condition shows as Yang condition (such as Yang hotness symptoms, for example, bitter taste in mouth, red color in urine, slight frequent pulse), treat it with a Yin therapy (to nourish the Yin to clear the hotness). This is no doubt. However, Master Zhongjing Zhang also said, if the condition shows as Yin condition, treat it with Yang therapy (to nourish the Yang aspect of the body). This is because the things in the world always have exception. If the Baihe disease is usually showing as a Yin condition, it would have a exceptional Yang condition too, which should be treated with a Yang-nourishing therapy. In the book, it did not show which herbal formula should be used, but the herbal formula of Banmai Dazao Tang is apparently the choice.  

 

(4).  胁下偏痛

(4). Pain under the rib and on the side of the belly

腹满寒疝宿食病脉症并治第十载: 胁下偏痛、发热、其脉紧弦,此寒也,以温药下之,宜大黄附子汤。

In the Chapter 10, in the discussion of belly bloating, cold hernia, accumulation of previously indigested food, in the book <<Shang Han Lun>>, it states: if there is pain under the ribs and on the side of the belly, and if the person has fever and the pulse is tight and string, the condition belongs to a Cold condition. It should be treated with warm therapy to dispel the inside Cold. The herbal formula should be the Dahuang Fuzi Tang.

胁下者,胁以下也,所指不仅止胁下一处,还当包括少腹、睾丸,而这些地方恰值足厥阴肝经所过,于理当通;证诸实践,此方亦常用于慢性痢疾,慢性结肠炎、睾丸炎 (偏坠、肿大)

The region under the ribs here means the whole region under the lower edge of the ribs. It does not only means the exact region under the ribs, but also the region above the inguina and the testis, which of the region is just the passing region by Liver meridian. Since this herbal formula belongs to the Jueyin phase of the disease in the Shanghan Lun, so use the herbal formula in those regions is understandable. This formula is also used for the treatment of chronic dysentry, chronic colonitis, and testitis (the testis is swelling and falling).

 

(5).  赤小豆当归散

(5). Chixiaodou Danggui San

见惊悸吐衄下血胸满瘀血病脉证并治第十六: 下血,先血后便,此近血也,赤小豆当归散主之。

In the Chapter 16, in the discussion of the diagnosis and treatment of scare, palpitation, bleeding in nose, in urine and in stool, bloating feeling in chest and blood stagnation, in the book <<Shang Han Lun>>, it states: if there is bleeding in front of the stool, it suggests the bleeding spot is close to the anus. Use the Chixiaodou Danggui San for the treatment.

此肠风、痔、肛裂之出血,药用赤豆、当归,清热利湿,活血止血。程门雪先生指出:此方用之少验,与黄土汤不可同日而语,可见同是仲景之方,也有有效无效,不必古人之方尽可用也。我很佩服程先生这种实事求是的精神。以我粗浅的体会,用地榆、槐花、侧柏叶、黄连、银花、大黄当有效。

Such bleeding is due to the colon ulcer, piles, fistula, and annal fissure. The herb Chixiaodou and Danggui are used to clear the fire and to dispel wetness, to activate blood circulation and to stop bleeding. Dr. Xue-men Chen said: “This formula has been tested not be effective. It can not be compared with the herbal formula Hungtu Tang. Apparently, even for the herbal formula introduced by Master Zhongjing Zhang, some formula works and some not. It does not mean that the herbal formula by our ancestor all would work. I respect Dr. Chen for his honesty to truth. For my clinic experience, the use of herb Diyu, Huaihua, Ceboye, Huangliang, Yinhua and Dahuang should work.

(6).  赤丸

(6). Chi Wan (e.g. Red pills)

见腹满寒疝宿食病脉证并治第十: 寒气厥逆,赤丸主之。

In the Chapter 10, in the discussion of belly bloating, cold hernia, accumulation of previously indigested food, in the book <<Shang Han Lun>>, it states: for reversing cold hands and feet due to Cold Qi, use Chi Wan for the treatment. (Here the Chi means red in color and wan means pill in Chinese).

赤丸方:茯苓四两、半夏四两(一方用桂)、乌头二两()、细辛一两。上四味,末之,内真朱为色,炼蜜丸,如麻子大,先食,酒饮下三丸,日再,夜一服,不知,稍增之,以知为度。

Chi Wan contains herb Fuling 4 liang, Banxia 4 liang (in another version, it uses herb Guizhi), Wutou 2 liang (processed), Xixing 1 liang. Grind the herbs into powder. Add Zhusha (cinnabar) in. Fold with honey to form pills as bean in size. Take three pills after meal with wine for swallow. Repeat once during daytime and once at night. If there is no any herb-body reaction, increase the number of pills to take, until there is healing reaction.

此证为阳虚阴盛,证见厥逆,故治当破阴返阳,方中实以大辛大热的乌头与细辛、半夏为主药,茯苓只是作赋形剂用,少许朱砂只是作标记之用而已。从来释此方者,皆谓茯苓淡渗化饮、朱砂重镇降逆,看其用量仅用麻子大三丸,便知不过是想当然耳!

This is a Yang deficiency and Yin overwhelming condition with symptom of reverse cold in hands and feet. For the treatment, it is needed so to break the Yin and to restore the Yang. In the formula, it uses strong spicy and strongly hot herb Wutou, as well as Xixin and Banxia, as the main ingredients. The herb Fuling is used as a pill formation ingredient. The little amount of Zhusha is used as only as a mark. The scholar and doctor in history who explain this formula, all said the Fuling works to filter and dispel extra water from the body, and the Zhusha is heavy to suppress the reverse. By paying attention to its use of only three pills each time and the pill is only a size as a bean, it should be able to know that such explanation is ridiculous!  

仲景时代尚无十八反之说,此方即乌头、半夏同用者。新世纪教材金匮要略说: 方中用茯苓、半夏化饮,降逆以止呕,再用朱砂重镇降逆,并调和乌头与半夏两味反药之性,朱砂有这个作用么?请教。

In the time of Master Zhongjing Zhang (Han dynasty), there was no concept of such eighteen conflict of herb couples. In this formula, the use of the Wutou and the Baxia is supposed to be a toxic-enhancing herb couple. In the textbook by New Century publicasher for the book <<Jin Kui Yao Luo>>, it said: “the use of Fuling and Banxia are to dispel extra water, to turn down the reversed Qi so to stop nausea, and the use of Zhusha is to suppress the reverse, as well as to harmonize the conflict between the Wutou and the Banxia.”.  Has the Zhusha such harmonization function? I strongly doubt and let me know how do you know its function as such!

内真朱为色当在炼蜜丸之下。

The words “add Zhusha to in the powder” should be written after the words “make into pills”. Therefore, it means to make the pills with honey first, then add Zhusha to fold on the surface of the pills.

 

(7). 口吣僻不遂

(7). Mouth is crooked and fails to move.

中风历节病脉证并治第: 今注家,无一例外地将口吣僻解释为口眼歪斜。其实,仲景只是说口歪,并没说眼也歪。说文解字谓口吣,口戾不正也宛如右僻,一曰从旁牵也,也是说口歪。只言口歪而不及于眼,可见仲景当时观察之细,用词之准。

The original Chinese words are seen in the Chapter 5, in the discussion of the diagnosis and treatment of stroke and arthritis. The explainers all explain the old Chinese characters as the crooked mouth and eyes. In fact, Master Zhongjing Zhang only said it is the crook in the mouth, not the eyes. … Only mention the crook in the mouth but not the eyes, clearly indicates how precisely Master Zhongjing Zhang had his clinic observation and the precise in the word he choose to use!

 

(8).  病痰饮者,当以温药和之

(8). For the disease that is caused by phlegm and condensed water, use warm herbs to harmonize. 

见痰饮咳嗽病脉证并治: 论者咸以病痰饮者,当以温药和之是广义痰饮的治疗原则,也就是说,是包括狭义痰饮在内的诸饮的总治则。我以为此方是狭义痰饮即水在胃肠的主方。如以此为总则,则欠妥。

This words are seen in the Chapter in the discussion of the diagnosis and treatment of phlegm, condensed water and cough in the book <<Jin Kui Yao Luo>>. Whenever is discussed, the scholars and doctors all believed that this is the main principle in the treatment the phlegm and the condensed water. In another words, it is the principle to treat the broad concept and the narrow concept of the phlegm and condensed water. I disagree with this. I believe it is the treatment principle only for the narrow concept of the phlegm and condensed water, e.g. it applies to the phlegm and condensed water in the stomach and in the intestine. It is not proper to use it as the treatment for all kinds of phlegm and condensed water condition in the body.   

痰饮即水饮,当乘其停留未久,正气尚可支持之时,视水饮所在而因势利导,或发汗,或涌吐,或利尿,或泻下,攻之使去,因此仲景有小青龙汤、五苓散、十枣汤、己椒苈黄丸诸方之设。

For the treatment of the phlegm and the condensed water condition, the treatment should be as earlier as possible to take the chance when the body defense energy is still sufficient to struggle against the accumulated condensed water in the body. Depending on the spot of the accumulation of the condensed water, use either sweat therapy, or vomiting therapy, or urination therapy, or colon cleansing therapy to remove it out of the body. Therefore, Master Zhongjing Zhang has the herbal formula of Xiao Qinlong Tang, Wuling San, Shizao Tang, Ji Jiao Li Huang Tang, as so on, to be used in different conditions.

试问,悬饮水在胸胁,溢饮水在四肢,支饮饮气相结,如何温药和之来解决?张子和说饮当去水,温补反剧,就是指此而言。和,就是调和,虽然重要,但并非万能,饮邪结实之时,呼吸都困难了,其可调和乎?当攻不攻,势必遗害无穷!

Let me have an ask: if the condensed water is in the chest and water also spills to the arms and legs, how can you use “warm” therapy to solve the problem? Dr. Zi-He Zhang said: when there is condensed water, the therapy should be aimed to dispel the water. If the warm-nourishing therapy is used, the condition would be worse. Here what he means is just such condition. To harmonize is to reconcile. It is important, but not works always. When the condensed water is heavily accumulated in the chest so as the breath is very difficult, how can you “harmonize”? If the dispelling therapy is not used when it should be used, it makes the body condition worse!

当然,强调攻邪也非不考虑正气,而是要眷眷以正气为怀,在仲景处方中,如葶苈大枣泻肺汤、十枣汤之用大枣,小青龙汤在用麻、桂、辛、夏、姜的同时,又以甘草、芍药、五味子相配,使散中有收,刚柔相济。但不能说十枣汤、葶苈大枣泻肺汤、小青龙汤也属温药和之之方。

Of course, to emphasize the dispelling therapy does not mean that we do not need to take care of the body defense energy condition. Surely, in the use of the water-dispelling therapy, the body defense energy should be always cared. In the formula used by Master Zhongjing Zhang, such as the Qingli Dazao Xie Fei Tang, Shi Zao Tang, he uses Chinese Date; in the formula Xiao Qinglong Tang, he uses the herb Mahuang, Guizhi, Xixing, Banxia, and ginger, he also uses Gancao, Shaoyao and Wuweizi, so to make the herbal formula has a function to disperse and also to contract, and to dispel and to nourish, the same time, for the aim not to hurt the body defense energy status. However in such cases, we should not say that the Shi Zao Tang, the Qingli Dazao Tang, and the Xiao Qinglong Tang, all belong to the “warm” therapy.

 

(9). 乌头煎

(9). Wutou Jian

见《腹满寒疝宿病脉证并治第十》:  寒疝绕脐痛,若发则白汗出,手足厥冷,其脉见紧者,大乌头煎主之。

The herbal formula Wutou Jian is seen in the Chapter 10, in the discussion of belly bloating, cold heniea, accumulation of previously indigested food, in the book <<Shang Han Lun>>: if there is cold hernia which causes pain around the naval, and if the patient has “white” sweat, cold hands and feet, and the pulse feels tight, on the time the pain comes, use Da Wutou Jian as main formula for the treatment.

病属阳虚寒凝,腹痛绕脐,手足厥冷,脉紧,皆足以证之。对于若发(发作性)则白汗出白汗,历来有许多不同说法,以我的经验,无非是因疼痛剧而大汗出。

This condition belongs to Yang deficiency and Cold accumulation.  The pain around the naval, the reversing cold in hands and feel, and tight pulse, all can prove it. For the white sweat on the onset of pain, there are many different opinions to explain it. From my own experience, I believe that it is simply an ordinary sweat due to severe pain.

李某,与我素相识,一日,在县医院不远遇见,弯著腰,坐在门坎上,唇色惨白,口吐白沫,浑身冷湿。我问他哪里不舒服,李某说早晨来赶场,还好好的,一下子肚子疼痛厉害,县医院医生说是阑尾炎,要他准备好钱去手术。诊其脉沉紧,手足冰凉,腹痛正好在脐周,口吐白沫,舌淡苔白。我说这是寒疝,即肠痉挛,李某点头说,类似这样的发作一年有两三次。于是我用川乌头15克,蜂蜜三勺,老姜一块,煮四十分钟,顿服。李取药后即在亲戚家煎药,一服而痛止汗收。

There has been such as case. The patient was Mr. Li. I know him for a long time. One day, I met him not far from our county hospital. He bended and sat on the threshold of a door. His face was very pale. He spit white color saliva, and his whole body is with cold sweat. I asked him where he felt discomfort. He said that he had been well, before he came here this morning for market selling and buying. Suddenly he felt very much pain in the belly. The doctor in the hospital said he got appendicitis and he needed to prepare money for a surgical operation. His pulse felt deep and tight, and his hands and feet are ice cold. The pain spot was just around the naval. He spit white bobble saliva. His tongue was pink and the tongue cover was white in color. I said this is Cold hernia, e.g. intestine spasm. He nodded, and said he had such onset two to three times a year. So I used Chuan Wutou 15 g, Honey three teaspoons, old ginger one piece. I asked him to cook all the ingredients in water for 40 minutes, and to drink all the tea once. He got the herbs and lived in his relative’s home to cook the herbs. His pain and sweat stopped after only one drink of the herbal tea.

 

(10).  肝著

(10). Liver Zhe condition.

见《金匮要略、五脏风寒积聚病脉证并治第十一》: 肝著,其人常欲蹈其胸上,先未苦时,但欲饮热,旋覆花汤主之。

This condition is introduced in the Chapter 11, for the discussion of the diagnosis and treatment of all organs’ Wind-Cold accumulation in the book <<Jin Kui Yao Luo>>. It said: in the Liver Zhe condition, the person has willing to let other person to step with foot on his/her chest. Before the onset, the person tends to drink hot water. In such Liver Zhe condition, use the Xuanfuhua Tang as main herbal formula for the treatment.

旋覆花汤方:旋覆花三两、葱十四茎、新绛少许。

The Xuanfuhua Tang contains herb Xuanfuhua 3 linag, Chinese onion 14 stems, and Xinjiang little amount.

肝之气血郁滞不行,故谓之。胸胁相连,故言胸,实包括胁。尤怡说: 此肝虽著,而气反注于肺,蹈之欲使气内鼓而出肝邪,显然失之迂腐。,注家有多种解释: 1.足踏;2. 掏(右边为舀)之误,掏(右边为舀)为用手迫击;3.动也,按揉、叩击、捶打、足蹈其以振荡为目的者皆是;4.按摩。其实一个字就很能说明问题了:因为气血郁滞到于此,不得通畅,很不舒服,想请人用足去踩一踩,这样,气血就可以暂时得到流通了。初病但欲饮热,也无非是气血得热而行的意思。

That the Liver Qi and Blood circulation is in stagnated condition is called Liver Zhe condition. The chest is connected to the side of the belly, so when we mean the chest, it actually also means the side of the belley. Dr. Yi You said: “The liver is now in a Zhe condition, the Qi however spills and fills into the lung. Step on the chest is to press the Qi in the lung so to dispel the Liver Xie Qi.” This explanation is apparently some kind of groundless statement. The Chinese word “Dao” here has several meanings: (1), step with feet; (2), the word “Dao” is actually the word “Tao”. It is a error in write; It should mean to tap with hands; (3), movement action, such as by massage, by tapping, by step with feet, so to shake the body; (4), to massage. Actually, the word “has willing to” means a lot: the Qi and blood are stagnated here, not in circulation, and the person feels discomfort and has willing to let other person to help to release the bloating feeling by some ways as by stepping with feet. By this way, the Qi and blood can restore in the circulation condition. In the early stage of the disease, the person likes hot drinking. It is the same aim to release the stagnation by heat, since upon heat, the Qi and blood tend to circulate better.

原文有方名而无方,注家乃将妇人杂病之同名方补之。在妇人篇,此方主半产漏下,恐未合,用于肝著,_很对证。旋覆花,《神农本草经》谓主结气,胁下满,下气;新绛,即绯帛,清人医案中还用,后来就没有这味药了。因为染帛为绛的原料是茜草根,所以今天以茜草作新绛用。茜草别名血见愁,有活血行血通络的作用。至于葱,则取其辛通。

In the original text, it indicated the name of the herbal formula, but did not show the exact ingredients. Previous scholars cited the herbal formula from the Chapter for female various diseases to fill up here. In that chapter, this formula works to treat “abortion and bleeding from uterus”. I doubt its use in this female disease, but it might be suit for the Liver Zhe condition. The herb Xuanfuhua is indicated in the book <<Shen Nun Ben Cao Jing>> that it works to release the stagnated Qi, to release bloating in the region that is under the ribs and on the side of the belly, and to move the Qi downwards to dispel.” The ingredient Xinjiang is red dyed silk. It was used in the case reports from doctors in the Qin dynasty, but not in later doctors’ clinic case reports. Since the colorant to dye the silk into red color is the root of the Qian grass, the root of the Qian grass is used as the Xinjiang. The nickname of the Qian grass is “Xuejiancou”, which has function to stimulate blood circulation and to conduct the meridian. The Chinese onion is used for its spicy conducting function.

叶天士对此方大为欣赏,称之为络方,在《临证指南医案》胁痛门,如沈案、朱案、汪案,都用旋覆花汤加味。

Dr. Tian-shi Ye admired this formula very much. He called this formula as “meridian formula”. In his book <<Lin Zhen Zhinan Yi An>>, Chapter pain under the ribs, such as in the case of patient Shen, Zhu, and Wang, the Xuanfuhua Tang was always used, though with little modification.

 

附录笔者治验一例:

One successful case of my own:

肖某、女、57岁,大学职工。2001512日。左乳下连及胁肋疼痛持续6天,刺痛夜甚,影响睡眠。眼眶周围黑,舌淡黯,脉沉弦。已去医院作过多项检查,仅心电图示ST段轻度缺血。病为肝著,由肝气郁滞,久而入络所致,用旋覆花汤加减:旋覆花10克、茜草10克、当归须10克、桃仁10克、丹参15克、川芎6克、赤白芍各10克、香附10克、全瓜蒌30克、降香6克、青葱管6根,6帖,应手而愈。

Mrs. Xiao, female, 57 years of old. Stuff in an University. She visited me at May 12, 2001. She had pain under her left breast, which expanded to the left side of the belly. The pain was continuous and very sharp and it was worse at night for 6 days, so that the sleep was affected. The surrounding area of the eyes was dark, the tongue was less red, and the pulse felt deep and string. She had been in hospital for various tests. The only finding was the slight ischemia from the St stegment of the ECG. In Chinese medicine, her condition was considered as Liver Zhe condition. Due to the Liver Qi stagnation, for a long time, the condition develops into the meridian. She was given the Xuanfuhua Tang with some modifications: Xuanfuhua 10 g, Qiancao 10 g, Danggui tail 10 g, Taoren 10 g, Danshen 15 g, Chuanxiong 6 g, Chishao 10 g, Baishao 10 g, Xiangfu 10 g, whole Gualu 30 g, Jiangxiang 6 g, green Chinese onion 6 stems. After six doses, her condition was improved completely.

 

2.  小青龙汤

2. Xiao Qinglong Tang

 

伤寒表不解,心下有水气,干呕,发热而咳,或渴,或利,或噎,或小便不利,或少腹满,或喘者,小青龙汤主之。 见《伤寒论》太阳上篇第39条。

When the body surface phase in the Shanghan disease is not released, the person has extra water accumulation in the stomach region, the person has nausea without vomit, and has fever and cough. The person may also have thirsty, or diarrhea, or hiccup, or difficulty in urination, or bloating feeling in the lower belly, or asthma. In this case, use Xiao Qinglong Tang as the main herbal formula for the treatment. – This paragraph is the 39th paragraph in the book <<Shang Han Lun>>.

伤寒表不解五字,即寓恶寒、发热、无汗、脉浮紧、或头痛身痛在内。水气之成,缘于水气积蓄在体内,影响所在脏器的功能,射肺则咳、喘;留胃则噎、干呕;蓄于中,则阻遏气化,津不上承而渴;在下则小便不利,而少腹满;水聚于肠,则下利(水泻),变证多端,不一而足。外寒与水气,同属阴邪,内外合邪而为小青龙汤证。表邪宜温散,故用麻桂,水饮宜温化,故用半夏、干姜、细辛温散之品以行水饮;而又恐辛散太过,又用白芍以监麻桂,五味子收敛肺气,正是组方心思缜密处。徐灵胎因此而说此方无微不利,真神剂也。

That the body surface phase is not released means that the person still has chilly, cold-fearing feeling, fever, no sweat, the pulse is floating and tight, or the person has headache, or body pain. The outcome for the extra water is because the accumulation of water inside the body affects the function of the organ where the extra water locates. When the extra water is in the lung, the person would have cough or asthma; in the throat, the person has chock, or dry nausea; in the middle part of the body to prevent the water rising to wet the mouth, the person has thirsty; in the urine bladder, the person has difficulty in urination or bloating feeling in the lower belly; in the intestine, the person has diarrhea (water-like diarrhea). There could be multiple variations in the symptoms. The external Xie Qi and the extra water both belong to Yin Xie. The condition caused by the combination of the external Xie Qi and the internal Water Xie is the indication to use the Xiao Qinglong Tang. The external Xie Qi needs to be expanded out, so use the herbs Mahuang and Guizhi. The extra Water Xie needs to be warm-evaporate, so use the herb Banxia, dried ginger and Xixin. For worry of over-expanding, use the herb Baishao to prevent it, and use Wuweizi to restrain the lung Qi. Apparently the formula is organized in a very careful manner. For this, Dr. Ling-Tai Xu said: “The formula works very good. It is a mysterious formula.”

四十多年来,我用小青龙汤甚多,只要是外寒内饮之证,往往投杯即效。三十多年前,在四川,有两个双胞胎男孩,其时方二岁多,生下来不久即患喘咳,此次又发作而住院治疗,我查房时,见两个孩子站在床上,不能卧下,张口喘气,状甚可伶。我用小青龙汤二剂,一剂即喘平大半,再剂即双双获愈。

For 40 years, I used this formula a lot. Once the body condition belongs to the both exist of external Cold Xie Qi in the body surface phase and extra water inside body,  it works very fast. Thirty years ago, in Sichuan province of China, there were twin boys, who were only little bit more than two years of old. They suffered from asthma right after birth. This time again, they were admitted in hospital due to the asthma. When I made the rounds in the wards, I saw them both stood on the bed, hard to lie down, had breath with open mouths. They looked very pity. I prescribed them the Xiao Qinglong Tang two doses. After one dose of the treatment, their asthma subsided half. After another dose, the asthma of both boys completely stopped.  

又有董某,咳嗽月余,痰稀如水,夹风泡,背冷如掌大,脉沉弦,已服过中西药半月无效。我用小青龙汤三付。其人因在武斗中误伤人命,判刑三年,出狱后即来致谢,说我开给他的药吃完后就进去了,几年来在里面一直未犯过咳嗽。

Another case is a person with family name Dong. The person suffered from cough for several months with phlegm clear as pure water and with wind-bubble in the phlegm. The person felt cold on the back in a size of palm. The pulse felt deep and string. The person had been using herbal therapy, as well as western medical treatment for half month without any effect. I used Xiao Qinglong Tang for three doses for the person. He had killed another person during the Cultural Revolution period and had been kept in prison for three years. After his release, he came to thank me for the treatment. He said that he finished the herbal therapy that I prescribed to him before he was kept in the prison. For the years he was in the prison, he had no any onset of cough at all.

小女何沂,体质偏寒,最近因咳嗽不已来电话索方,询知其在空调车、空调房中即咳,此刘渡老所谓空调病也,即投小青龙汤,仅一服即止。

My daughter Yi He is with body constitution of cold side. She called me recently asking for herbal therapy for her continuous cough. I asked and knew that she had cough when she stayed in are-conditioning car or room. This is what Dr. Du-zhou Liu said the “air-conditioning disease”. I asked her to have the Xiao Qinglong Tang for one dose. The only one dose stopped her cough.

小青龙汤亦见于《金匮要略》痰饮篇中。其文云咳嗽倚息,短气不得卧,其形如肿,小青龙汤主之。并不言伤寒表不解,可见单是痰饮,即无外寒,亦可用之,盖麻桂同用,可宣可温,大可用于肺寒气逆之证。

The Xiao Qinglong Tang is cited in the Chapter of phlegm and condensed water of the book <<Jin Kui Yao Luo>>. It said: “if the person has cough, hard to breath when lies down, and if the person looks as swelling in face, use Xiao Qinglong Tang for the treatment.” It does not say “if the body surface phase is not yet released”. Apparently, even if there is no external Cold Xie in the body surface phase, it can still be used. The reason is that, the herb Mahuang and Guizhi, when used together, can work both to expand and to warm up, so can be used in the Cold lung and Qi reversing condition. 

小青龙汤的方后注,仲景有加减法:若渴者,去半夏,加栝蒌根(即天花粉)。小青龙汤本可用以止渴,不过此渴乃水饮阻遏,津不得上承之假渴;真渴,则真的是津液亏耗,久病咳逆者多有此证,其证必咽干口燥,舌红而干,所以去半夏加天花粉,此为仲景的权变之法,天花粉不滋腻,和天麦冬不一样,不至有留邪之弊。

In the appendix for the Xiao Qinglong Tang, Master Zhongjing Zhang has examples for the modifications: if the person has thirsty, remove herb Banxia but add Guolugen (e.g. herb Tianhuafeng). The Xiao Qinglong Tang is initially able to stop thirsty. However, the thirsty in this case is due to the block of water from the lower part of the body to rise up to wet the mouth and throat. It is a false thirsty. A true thirsty means the exhaustion of water part in the body, as mostly seen in a long term course of cough and asthma, in which the person feels dry in mouth and throat, the tongue is red and dry. For this reason, Master Zhang removed Banxia and added Tianhuafeng. The herb Tianhufeng is not greasy, unlike the herb Tianmendong or Maimendong, not to keep the Xie Qi inside the body.

若微利,去麻黄,加荛花如一鸡子。利是下利,这里是因为饮邪走下,水饮去,则利自止。荛花,为瑞香科植物之花,《神农本草经》、《本经别录》、《千金要方》、《本草纲目》均载,谓其辛苦寒,有毒,入肠胃,功专泻水饮,治留饮咳逆上气及水肿。但不知何故此药久已废用。徐灵胎说本草芫花、荛花,花叶相近,而荛花不常用,当时已不多得,故改用芫花,以其皆有利水之功也。十枣汤中甘遂、大戟、芫花同用作散剂,泻水力相当峻猛,若单用芫花一味,且用小剂量入汤剂中,不是作散剂,则泻水之力就不强了。北京已故老医生张菊人先生曾治一水肿患者,喘满并作,颇以为苦,张先生即用小青龙汤加芫花五分,泻水数十遍,次日即喘平肿消。能有如此之效,以我的阅历,则非作散剂不可。

If there is slight diarrhea, remove herb Mahuang, but add Raohua, a size of a chicken egg. The diarrhea is due to the extra water move down. After the removal of the extra water, the diarrhea stopped by it self. The herb Raohua is a kind of flower of a plant thymelaeaceae. It has been introduced in book <<Shen Nun Ben Cao Jing>>, <<Ben Jing Bie Lu>>, <<Qian Jin Yao Fang>>, and <<Ben Cao Gang Mu>>. It said that it is spicy and bitter in taste, is with poisoning effect. It goes into the stomach and intestine, and works to dispel extra water, to solve cough and asthma due to reverse of extra water in the body, as well as the swelling condition. However, for an unknown reason, it is no longer used. Dr. Ling-tai Xu said: “In the book <<Ben Cao>>, the herb Yuanhua and the Raohua are similar in their leaves and flowers. The Raohua is not commonly used, for it is not well available at that time. So the Yuanhua is used to replace the Raohua, for both have similar effect of dispelling extra water.” In the herbal formula Shizao Tang, the herb Gansui, Daji and Yuanhua are all used as powder form. Their water-dispelling effect is very strong. If the Yuanhua alone is used, and if it is used in cooking herbs, not as powder form, its water-dispelling effect is not strong. Dr. Ju-ren Zhang, in Beijing, China, treated a patient with swelling, who had both short of breath and bloating and suffered a lot. Dr. Zhang used the Xiao Qinglong Tang plus Yuanhua little. The patient had water-like diarrhea tens of times a day. On the next day, the asthma and swelling both subsided completely. To have such strong healing effect, for my experience, it must be used as powder form. 

,去麻黄,加附子一枚()。这里的,《外名》作饮食噎者,水饮挟胃气上逆,吃饭喝水有噎塞不适之感。也有噫气频频者。附子大辛大热,干姜、桂枝、半夏得附子之助则水饮速化,胃气安和矣。

If the person has choke in throat, remove herb Mahuang, but add one Fuzi (processed one). The word “choke” here is explained in the book <<Wai Tai>> as a stagnation feeling in throat when drink or eat. The condensed water rushes up with the stomach Qi, so to cause the stagnation and choke feeling in the throat when drink and eat. For some persons, they may feel as frequent ructation. The herb Fuzi is strong spicy and strong hot. When the herb dried ginger, Guizhi and Banxia are used together with the help from the Fuzi, the extra water would be evaporated or dispelled faster, so the stomach Qi become calm easier.

小便不利,少腹满,均是水饮停蓄于下之故,所以加茯苓利水。

The symptoms of hard urination, bloating feeling in the lower belly, are due to the accumulation of water in the lower part of the body. Therefore the herb Fuling is used to remove the extra water.

喘去麻黄,加杏仁,取杏仁降逆下气之功,利、噎、喘、小便不利、少腹满为甚么都要去麻黄?过去不少注家对此方后注表示过怀疑,认为不是仲景之文。《医宗金鉴》说是远表而就里也,也就是说,上述五证都是里证,所以去麻黄之散外寒,以免分散主攻方向,但仍然保留桂枝,以桂枝既可解外,又可治内,有平冲、化饮之功。说服力似乎不强。

If there is asthma, remove herb Mahuang and add Xinren, for the Xinren works to down-direct the reversed Qi. Why the herb Mahuang should be deleted if there is diarrhea, choke in throat, asthma, hard urination, and bloating in the lower belly? Many scholars in history have had doubt if it is the original version by Master Zhongjing Zhang. In the book <<Yi Zhong Jin Dina>> , it said that to depletion of Mahuang for the reason that the herbal formula is to solve the body inside problems, not a body surface phase problems, e.g. the above five symptoms are from an inside illness in the body. To delete the Mahuang of its function of dispelling external Cold Xie, is to avoid of disperse of the healing target. That the herb Guizhi is kept, for the Guizhi works both to solve external Xie Qi and to solve inside disorders, such as to calm down the reversed Qi rushing, and to dissolve phlegm. To me, these explanations seem not convincing. 

以我使用小青龙汤的经验,这五个加减法都不大常用。最重要的,有三种见证,一是外寒内饮,又郁热在里,不得发越,而烦躁脉数者,加石膏,见《金匮》肺痿肺痈咳嗽上气篇。二是北方干燥,饮邪挟热最常见,故常加石膏,俾寒饮郁热一药而廓清。三是阳虚之体,证见畏寒喜嗳,背心足底发冷、舌质淡,苔水滑,脉沉弦者,加入附子,其效立见。(半夏不反附子,完全可以同用。)

To me, these five modifications for the Xiao Qinglong Tang are not commonly used. The most important is three conditions. One is the co-exist of external Xie Qi in the body surface phase, the extra water accumulation inside, as well as a choked Fire developed inside the body which is hard to dispersed off to cause annoying feeling, showing as frequent pulse. In this case, add herb Shigao, as indicated in the chapter for the discussion of atrophic lung disease, lung carbuncle, and cough, in the book <<Jin Kui>>. Second, the weather in north is dry, it is common that the extra water condition is combined with the choked Fire inside body. So the herb Shigao is commonly added in the formula. The third is seen in Yang deficiency body. The person dislikes cold and likes warm, feels cold in the sole or on the back. The tongue is less red in color, and the tongue cover is water-slippery. The pulse is deep and string.  The addition of Fuzi in the Xiao Qinglong Tang would make the healing much faster. (The herb Banxia does not conflict against the Fuzi. They can be used in the same formula).   

此外,年老体弱或有心悸怔忡病史,不任发越者,我常用以下三法,一是学叶天士去麻黄、细辛;二是学范文虎法,除半夏用10克外,余者仅用数分;三是学张锡纯服小青龙得效后,即改用其自拟的从龙汤(生龙骨、炮牡蛎各30克、白芍15克、清半夏12克、炒苏子12克、牛蒡子10)二、三剂以收功。吴鞠通也指出过小青龙汤非常服久服之剂,见效后当改用苓桂术甘汤加半夏、生姜、苡仁、茅术理脾化饮。张吴两位的用药,各有取义,吾侪当视其不同见证,临病制方,师其意不泥其方可也。

In addition, for those of persons who are elderly and weak in body condition, or have history of palpitation, so their bodies do not allow a strong dispersing-expanding therapy, I use the following three ways to solve this problem. First, I learned from Dr. Tian-shi Ye, to delete Mahuang and Xixin. Second, I learned from Dr. Wen-hu Fang, to use Banxia 10 g, but other herbs are used for only less than 1 g. The third way is to learn from Dr. Xi-chun Zhang, to use the Xiao Qinglong Tang first to get healing effect, then change to his Conglong Tang (Longgu 30 g, Pao Muli 30 g, Baishao 15 g, Qing Banxia 12 g, Chao Suzi 12 g, Niubangzi 10 g) for two to three doses to stop the healing process. Dr. Ju-tong Wu also pointed out that the Xiao Qinglong Tang should not be used for a long time. After getting the healing effect, the formula should be changed to use Ling Gui Zhu Gan Tang plus Banxia, fresh ginger, Yiyiren and Baizhu to nourish the spleen and to dissolve the condensed water. The ways of Dr. Zhang and Dr. Wu have different advantages. We need to use their way according to the clinic conditions, to organize the formula when facing each patient. We need to following their principle but not necessary the exact formula.  

 

3. 半夏泻心汤及其变方

3. Banxia Xiexin Tang and its variations

 

《伤寒论》的五个泻心汤中,生姜泻心汤、半夏泻心汤、甘草泻心汤三方的用药较为近似。半夏泻心汤为三方中心,生姜、甘草二方可视为半夏方的加减方。

Among the five Xiexin Tang introduced in the book <<Shang Han Lun>>, the Shenjiang Xiexin Tang, Banxia Xiexin Tang, and Gancao Xiexin Tang are pretty similar. The Banxia Xiexin Tang is the basis and the Shenjiang Xiexin Tang and the Gancao Xiexin Tang can be regarded as the modifications of the Banxia Xiexin Tang.

原文说伤寒五六日,呕而发热者,柴胡汤证具,而以他药下之,可有三种情况:一、柴胡证仍在者,复与柴胡汤;二、若心下满而硬痛者,此为结胸也,大陷胸汤主之;三、但满而不痛者,此为痞,柴胡不中与之,宜半夏泻心汤。

The original text said: “On the fifth or the sixth day of the Shanghan disease, the person feels nausea and has fever, and there are some other signs for the use of herbal formula Chaihu Tang, but the person is given colon-cleansing therapy (to cause diarrhea), there would be three different results and three different corresponding therapy to solve the mis-treatment. First, “If the conditions (the symptoms) are still exist for the use of Chaihu Tang, continue to use Chaihu Tang for the treatment.”  Second, if the person has bloating feeling in the stomach region and this region feels hard and the person feels pain, it is a Jiexiong condition (e.g. strong bloating feeling in the chest), use Da Xianxiong Tang as the main formula for the treatment. The third, if the person only feels bloating but not pain, it is a simply bloating condition. If the use of Chaihu Tang does not work, change to Banxia Xiexin Tang.”

半夏泻心汤的主证,这里点明了,是。心下,即胃,也就是胃部痞满。叙证简略,以其用药测证,还当有恶心、呕吐、肠鸣、下利与其它消化系的症状。

The main indication for the use of Banxia Xiexin Tang, here it has been indicated clearly, is the “bloating or fullness feeling”. The “under the heart” means the stomach area. Implied from the ingredients of the herbal formula for the possible other symptoms, the person should have also nausea, vomit, noise in intestine, diarrhea or some other digestive system symptoms.

误下必致中虚,中虚则纳与运,皆受影响,这当然与患者平素脾胃就不健,中气虚寒夹湿有关,少阳之热邪乘虚而内陷,遂至中虚-寒-热错杂,中焦失其升降之机故痞满;胃气当降而反上逆,故呕恶;脾气当升而反下降,故肠鸣腹泻。其治当补脾胃之虚,而用人参、甘草、大枣;加上半夏、干姜辛热散寒,黄芩、黄连苦寒泄热,即为补中兼辛开苦降法,中气健,寒热去,升降复常,痞满呕利自已。证之临床,当见舌质红、舌体胖大齿痕、舌苔黄腻而厚。亦确多但满不痛,但也有痞满而兼疼痛者,此外,也未见得是在外感病太阳、少阳下后出现此证,只要是平素中虚挟寒湿,复患热邪,或寒湿久蕴而化热,都可出现半夏泻心汤证,这样的病机在杂病颇为多见。

An improper use of colon-cleansing therapy would definitely cause weakness (deficiency) condition in the middle part of the body (the stomach and intestine area). If the digestive system is in weak condition, the appetite and the digesive function of the body would be affected. This outcome, of course, could be related to the initiral poor condition of the digestive system, in which the middle weakness is combined with Cold and wetness. In this case, the Shaoyang hotness Xie Qi would take the chance to invade and penetrate into the weak digestive system, so to form a middle weakness-cold-hotness mixture condition.  That the middle stomach area is in disorder of the Qi rising or going down causes bloating feeling in the belly. That the reversely rising of the stomach Qi, that should go down in normal condition now causes nausea. That the Spleen Qi reversely goes down, that should rise up in normal condition, causes intestine noise and diarrhea. To solve this disorder, it should be aimed to nourish the Spleen and Stomach and to solve their weakness, by using herb Renshen, Gancao and Chinese date. The herb Banxia and dried ginger are spicy and hot, so to disperse Cold, and the Huangqin and Huanglian are bitter and cold, so to dispel Fire in the body. All together, the formula works to nourish, to disperse and to dispel. When the middle Qi is in sufficient, the Cold and Fire are removed, the Qi in the stomach area turns normal in its rising and going down, so that the bloating, the nausea and the diarrhea stop automatically. Inferred from the herbal ingredients, the patient should have red tongue, big size tongue with teeth index  on the sides, and thick and yellow tongue cover. In deed, most of the patients would feel only bloating feeling but no pain, though small number of them may feel both bloating and pain. In addition, Not all the patients with such problem are due to the misuse of colon-cleansing therapy when their disease is still in the Taiyang or Shaoyang phases. For some, who usually has weak digestive function with also accumulation of Cold and Wetness in the digestive system, may have the same Cold-Hotness syndrome after they catch external Hotness Xie Qi. Or, some may have a long time of accumulation of Cold-Wetness in the digestive system, which develops into Fire eventually, so as to cause such Cold-Hotness mixture syndrome in the body.

邝某,年70余,华侨。其人消瘦、倦怠、食后即觉胃胀,自诉就像甚么东西搁在胃部不走了,必等二、三个小时后才缓解,下一餐又复如此,颇以为苦,因此而饮食减少,便溏不爽。舌淡胖、齿痕、苔色白黄相间而腻,脉滑数,重按无力。此痞证也,用半夏泻心汤三付。上午服药,下午即来电话,说药后胃部叽叽咕咕,一付后,顿觉开快,欣然能食矣。

 Ms. Kuang is 70 years of old. He is very slim, tired, feels stomach bloating after meal. He described that he felt as something blocked in the stomach without moving down. Such feeling needed to wait for two to three hours to subside. It happened for next meal again. He suffered from this feeling a lot, so that he has reduced appetite, and has loose bowl movement with stool retention feeling after the bowel movement. His tongue is less red in color with slight bigger in size and with teeth index on sides. The tongue cover was white-yellow mixed color with greasy look. The pulse was slippery and frequent and it felt weak when press harder. This is the bloating syndrome. He was given the Banxia Xiexin Tang three doses to take. He took the herbal tea in the norning and he called me back in the afternoon and said that, after taking the herbal tea, he felt big moving noise in the stomach, that he felt soon much release feeling from the stomach. He was so happy that he could eat as will again.

生姜泻心汤即半夏泻心汤减干姜之量(由三两减到一两)加生姜四两而成,其证胃不和,心下痞硬,与半夏泻心汤相似,半夏泻心汤但满不痛,胃部按诊是软的,生姜泻心汤有痞满,按之却稍硬一些,此外更多食臭”“胁下有水气(胁痛),腹中雷鸣、下利,显然与半夏泻心汤同证又挟水饮,即胃部停水,此外还有不消化之饮食、气机滞塞不通,如无有形之物还好,夹有形之物,症状然就会重一些。处方依然以和中消痞为法,但重加生姜为君,既能散水,又可健胃。

Shengjiang Xiexin Tang (here the Shengjiang means the ginger, but it is better to continue call it Shengjiang in Chinese) means to reduce the amount of dried ginger (from 3 liang to 1 liang) and add fresh ginger 4 liang in the Banxia Xiexin Tang. It works to solve the “The stomach feels not good. It feels bloating and also hard when press with hand”, similar to the indication to the Banxia Xiexin Tang. However, for the Banxia Xiexin Tang, the person felt bloating but not pain basically and the stomach area is soft when press or touch. For the Shengjiang Xiexin Tang, the patient feels bloating, no pain, but the stomach feels harder when press with hand. In addition, for the Shengjiang Xiexin Tang, the person feels also “dry belching with bad, not digested food odor from mouth”, “big gas noise in the intestine with diarrhea”. Apparently, for the Shengjiang Xiexin Tang,  there is watera accumulation condition in the stomach with non-digested food, both of which block the stomach Qi to go down and the Spleen Qi to rise up. Usually, if there is no concrete material block in the digestive system, the symptoms would be less severe. If there is such material, such as non-digested food, phlegm, dead blood, worms, or dry stool mass,  in the digestive system, the symptoms would be more severe. For the treatment, the herbs remain to mostly solve the disorder of the Qi moving up and down in the digestive system to release the bloating, but need more function to disperse water and to nourish the stomach, by adding more fresh ginger.

甘草泻心汤即半夏泻心汤重加炙甘草(由三两增至四两),《伤寒论》脱人参,林亿谓是脱落,诚是。其证下利日数十行,谷不化,腹中雷鸣,心下痞硬而满,干呕、心烦不得安,此下利较之生姜泻心汤更重,原文指出是太阳病误下,而为胃痞,医谓病不尽,复下之而成,显然是一逆再逆,重虚胃气,故其痞不仅不除,反而更甚,正虚邪陷,故重用甘草以补其虚,半夏、干姜、黄芩、黄连不仅辛开苦降治痞,呕吐下利亦都可以解决了。

The Gancao Xiexin Tang is developed also from the Banxia Xiexin Tang, by adding more Zhi Gancao (from 3 liang to 4 liang. In the book <<Shang Han Lun>>, there is no herb Rehshen for this formula. Dr. Yi Lin believed that it is missing. I agree. The condition for the use of the Gancao Xiexin Tang is diarrhea more than ten times a day with non-digestive food in the stool, with big intestine noise in the belly. The stomach area feels bloating, and hard when press. There is nausea without vomit, annoyed feeling and hard to be rest. The diarrhea is more severe than the Shengjinag Xiexin Tang. In the original text, it says this formula is used in a condition when the colon-cleansing therapy is mis-used in the Taiyang phase of a disease, so cause such stomach bloating feeling. The colon-cleansing therapy causes severe weakness condition in the digestive system. Therefore, large amount of herb Gancao (licorice) is used to nourish the heavily damaged stomach, and the Banxia, Dried ginger, Huangqin and Huanglian to restore the normal down-going stomach Qi and the up-rising Spleen Qi, so to solve the nausea and diarrhea.

痞为上下不通泰之意,原文说:干呕心烦不得安,点明上热;下利、肠鸣、谷不化,点明下寒,也就是胃热肠寒。但也有认为是上寒下热即胃寒肠热的。实际上,其证本来就是中虚而寒热错杂,胃热肠寒也好,胃寒肠热也好,此方都能用的。三泻心汤证大同小异,用药于小异中有变化,足见仲景辨证用药之细微严密,学者若能于此用心探求,将大有益也。

Bloating feeling indicates the block of the Qi in the digestive system: the stomach Qi fails to move down and the spleen Qi cannot rise up to form Qi circulation in the digestive system. In the original text, it says: the person has dry nausea and annoyed restless feeling, which suggests there is hotness in the upper part of the body. The symptoms of diarrhea, intestine noise and the non-digested food in stool, all indicate the presence of Cold in the lower part of the body. That means there is both Hotness (Fire) and Cold in the body, e.g. a Cold-Hotness mixture condition in the body. Some doctor believes that is a Hotness-stomach and Cold-intestine condition. Some others believe that it is a upper-Cold but lower-hotness condition, e.g. Cold-stomach and Hotness-intestine condition. In fact, this is a weakness condition in the digestive system with both Cold and Hotness condition. No matter it is Cold-stomach, Hotness-intestine, or a Hotness-stomach and Cold-intestine condition, the Gancao Xiexin Tang can be used. The three Xiexin Tang share the similarity but sill show some minor difference, suggesting that Master Zhongjing Zhang’ carefulness in the diagnosis and herbal prescription. We need to learn from him.

于某,年30余,首钢工人,因高位截瘫住解放军某医院。胃痛胀半年余,始终不见好,某老医长期用疏肝理气药不效,近日又加入延胡索、罂粟壳,痛胀仍不止,乃邀我诊治。察其舌红、苔黄腻,脉滑数,询知嘈杂善饥,食后脘痞,我认为病属中虚湿热,治宜补中消痞,用半夏泻心汤加砂仁、蒲公英,二付后疼止,痞满亦消。痞证的特点是但满不痛,我理解这是为了区别于大陷胸证的痞硬而痛,此例则痞而痛。痞证也有可能出现疼痛的,中虚失运,寒热错杂,气机痞塞,不通则痛,于情理上当如是。

Mr. Yu is 30 years of old. He is a worker in an iron and steel factory in Beijing. He was admitted in hospital for higher level paralysis. He suffered from stomach pain and bloating for half years. He was treated in the hospital but no any improvement. He was also given Chinese herbal theray, which worked mostly to dredge liver and to conduct Qi, without improvement either. Laterly, he was given herb Yuanhu, Yinsuke, the pain and bloating was still severe. I was asked to have a consultation. His tonue was red in color. The tongue cover was yellow and greasy. The pulse felt slippery and frequent. He told that he felt discomform in the stomach with easy to feel hungry. He felt bloating feeling in the upper belly after meal. I considered that he had weakness condition in the stomach with hotness and wetness. The herbal therapy was prescribed to nourish the weakness and to dispel the hotness and wetness. The Banxia Xiexin Tang was used with addition of herb Sharen, Pugongying. After two doses, the pain stopped, and the bloating feeling subsided. The characteristic of the Bloating syndrome is the Bloating without pain. I understand that it is to separate from the condition for Da Xianxiong Tang, which works for both bloating, hard when press, and pain in the stomach area. In this case, the patient felt both bloating and pain, however. In theory, the bloating syndrome could also have pain, since when the digestive is weak to move the food down, the Hotness and Cold tangling in the digestive system, the Qi circulation in the digestive system is affected so to cause block in the digestive system. Once there is block, there could have a pain.  

 

黄连汤及干姜黄芩黄连人参汤亦半夏泻心汤的变方

The Huanglian Tang, and the Ganjiang Huangqin Huanglian Tang, are also the development from the Banxia Xiexin Tang

黄连汤即半夏泻心汤去黄芩,加桂枝而成,去一味,加一味,遂变治中焦痞呕之方,为平调上下之剂。黄连用量也有变化,由半夏泻心汤的一两加到二两。原文指证:  胸中有热,胃中有邪气,腹中痛、欲呕吐,论者多以为胸中就是胸中,胃有邪气,即胃有寒,如此竟与肠无关了。实际上仲景叙述部位,往往不那么准确,例如他说胃,很多时候就是指肠。大承气汤证胃中必有燥屎五六枚也,就是铁证。我对黄连汤的理解无非上热下寒而已。上热指胃,波及于心胸,于证,当见胃热上冲的欲呕吐以及言外之意的烦闷(胸中有热);所以重用黄连,独力泻心胃之火;下寒指肠,于证当见寒凝气滞的腹中痛,所以用干姜温下散寒。桂枝之用,并非为兼表证而设,事实上,与表证一点关系也没有。而是取其通达上下之力,使上热下寒,欲呕、腹痛的局面得以归于和解之途。其余用药,人参、甘草、大枣之补虚和中,半夏之助黄连降逆,桂枝之助干姜散寒,就不难理解了。

The formula Huanglian Tang is developed from Banxia Xiexin Tang by removal of Huangqin, but addition of Guizhi. By such one removal and one addition, the Banxia Xiexin Tang turns from a herbal formula that works to solve the bloating and nausea in the digestive system into one that works to harmonize the upper and the lower part of the digestive system. Among the deletion and the addition, the amount of Huanglian in the Banxia Xiexin Tang is also increased from 1liang to 2 liang. In the original text, the conditions to use the Huanglian Tang is said tobe “there is hotness in the chest, and Xie Qi in the stomach. There is pain in the belly and a willing to have nausea”. Most of the scholars and doctors believed that it means the hotness in the chest and the Xie Qi in the stomach means there is Cold in the stomach. It seems that there is nothing to do with the intestine. In fact, whenever Master Zhongjing Zhang tells about the location of the disease, he usually does not describe exactly. For example, when he said it is stomach, but he actually meant the intestine also. For example in the herbal formula Da Chenqi Tang, he said “there must be five or six balls of dried stool in the stomach”. Apparently, the dried stool balls should be in the intestine, not in the stomach. I understand that the indication for the use of Huanglian Tang is simply the upper hotness and lower cold condition in the digestive system. The upper means the stomach and expands to the heart and chest area. For the symptoms, the person should have a willing to nausea, as well as a reference to the “annoyed” (there is hotness in the chest). For the hotness, the Huanglian is used as a large amount, focusing to deplete the Fire in the stomach and heart. The lower cold means the intestine. For the symptoms, the person should have “belly pain” due to Cold stick and Qi sluggish in the intestine. For this cold, the dried ginger is used to warm off the cold. The use of Guizhi is not to disperse cold on the body surface phase. In fact, there is nothing to do with the body surface. The use of the Guizhi is to conduct the upper and the lower part, to harmonize digestive system by evening the upper hotness with lower cold, so to solve the nausea and the belly pain. The use of other herbs, the Renshen, Gancao, Chinese date, is to nourish the digestive system and to calm the middle part of the body. The Banxia is to help the Huanglian to reverse down the stomach Qi, and the Guizhi is to help dried ginger to disperse the cold. It is not hard to understand.

 

干姜黄芩黄连汤,从其药物组成说则半夏泻心汤去甘草、半夏、大枣而成,大体仍以寒温并用为法,治疗上热下寒之证,上热则心胸烦热(胃热熏蒸),饮食入口即吐,下寒则腹泻腹痛,故用芩连清胃,人参干姜温脾,苦降则呕吐可止,不烦半夏之降逆;温脾则泄利自愈,无劳苓术之健脾。柯韵伯说凡呕家发热者,不利于砂橘半,服此方晏如。 此方我常用于妊娠恶阻剧吐,心烦舌红苔黄脉数者。

Ganjiang Huangqin Huanglian Tang. From its herbal ingredients, it can be seen a development from Banxia Xiexin Tang, by deletion of Gancao, Banxia and Chinees date. It is still a herbal formula works to solve both hotness and cold in the digestive system, e.g. the upper hotness and lower cold condition. For the upper hotness, the person feels annoyed hot in the chest, movit once eat something. For the cold, the person has diarrhea and pain in the belly. The Huangqin and Huanglian are used to clear the stomach fire; the Renshen and dried dinger are to warm up spleen, so to solve the nausea without the use of Banxia to reverse the Qi, and to solve the diarrhea without the use of Fuling or Baizhu to nourish the spleen. Dr. Yunbo Ke said: “Whenever the person has nausea and fever, it is not good to use herb Sharen, Jupi and Banxia. The formula Ganjiang Huangqin Huangliang Tang works much better.”  I use this formula more in nausea in pregnancy, in which the person’s tongue is red in color, the tongue cover is yellow and the pulse is frequent.

旋覆代赭汤为生姜泻心汤的变方,即生姜泻心汤去干姜、芩、连三味,加入旋覆花代赭石二味。其证与生姜泻心汤相比较,相同的有心下痞硬,不同的是生姜泻心汤,还有腹中雷鸣,下利。又噫气不除不除,噫气频频之谓,干噫食臭,噫和干噫同义,都是指嗳气,即只是嗳气,而无食物随之而出;食臭,则指有不消化食物的腐馊气味,此则为旋方所无。所以楼全善说病解后,心中()痞硬,噫气,若下利,此条旋覆代赭汤也。若不下利者,前条生姜泻心汤也。徐灵胎也说: 此乃痞已向愈,中有留邪,在于心胃之间,与前泻心汤法,大约相约。

Xuanfu Taizheshi Tang is developed also from the Shengjiang Xiexin Tang. It is the removal of Ganjiang, Huangqin and Huanglian from, but add Xuanfuhua and Daizheshi into the Shengjiang  Xiexin Tang. For the symptoms associated with the Xhuanfu Daizheshi Tang, there are also “bloating feeling in the stomach area, where is felt hard when touch.” The difference is that, for the Shengjiang Xiexin Tang, the person has additional strong intestine noise and diarrhea, belching with bad odor from mouth. The Xuanfu Daizheshi Tang has stronger continuous belching but no bad odor in mouth. Dr. Quanshan Lu said: After the dissolve of a disease, and if the person still feels hard and bloating in the stomach, and has belching, and if he has also diarrhea, use the Xuanfu Daizheshi Tang for the treatment.” If there is no diarrhea, use the previous Shengjiang Xiexin Tang[2]. Dr. Lingtai Xu also said: “the Xuanfu Daizheshi Tang is used when the bloating disease is about to solved, but there is still some Xie Qi remaining in the digestive system….”

旋覆代赭汤多用于杂病,其人必脾胃素虚,因痰气上逆而致心下痞硬,噫气频频者。方用人参、甘草、大枣,补脾胃。生姜用量独重,比甘草泻心汤之四两还多一两,是因其既能健胃,又能降气化饮。半夏既能温化痰饮,又能降气散结。旋覆花既化痰又行气,赭石既重镇降逆又可坠痰。药取两用,故于痰凝气结的病机十分切合。

The Xuanfu Daizheshi Tang is usually used in various miscellaneous diseases. The person must have weakness in the digestive system for a long time. Due to the reverse rising up of the phlegm Qi, the person feels hard and bloating in the stomach, as well as continuous belching. In the formula, the Renshen, Gancao and Chinese date work to nourish the digestive system (the stomach and the spleen). The dose of fresh ginger is very much higher. It is even one liang more than that in the Gancao Xiexin Tang, for its ability to nourish the stomach and to dispel the phlegm down. The Banxia works to warm up and to dissolve the phlegm and entangled mass in the digestive system. The herb Xuanfuhua is able to dissolve phlegm and to conduct the Qi circulation. The Daizheshi is heavy to suppress the reversed Qi and the suppress the phlegm down. The formula takes its two functions, so that it is suitable to be used in such condition with phlegm accumulation in the digestive system.

此方亦用于治疗胃虚痰气上逆而引起的呃逆,反胃。最善以此方化裁,更由消化系病扩大到呼吸系多种疾病的,是张锡纯先生。其自拟之参赭镇气汤、镇逆汤,治疗虚气上逆之胸膈满闷、喘逆、膈证、呕吐、恶阻、吐血,治验颇多。诚以临证日久,凡药之性情能力及宜轻宜重之际,研究四十多年,心中皆有定见,而敢如此放胆,百用不至一失。

This formula is also use to solve the belching and food-reverse syndrome due to the reverse rushing-up of phlegm Qi in stomach when the Stomach is in a weakness condition. It is the Dr. Xichun Zhang, who is good at modifying this formula, so that to use the diseases from digestive system to the respirotary system. He developed herbal formula Shen Zhe Zhen Qi Tang and Zheng Ni Tang, to treat fullness and bloating feeling in chest, asthma, belching, hiccup, nausea and vomit, nausea during pregnancy, blood-spitting, with pretty good results. He said “I have studied the nature and the function of various herbs for more than 40 years, and after a long time of clinic practice, I know how to use the herbs, so than I dare to use them without making mistakes in the clinic treatment.”

近世论者多认为此证为胃虚,标则为痰气,所以仲景赭石用量较小,唯恐其用量过重再伤胃气,此固一说也,证之实践,也不尽然。有谓赭石苦寒性味恐伤胃阳,因此每剂只用3克,赭石苦寒之说虽见于《神农本草经》,其实何苦之有?张锡纯《赭石解》说赭石性质和平,虽除逆气而不伤正气心气虚又佐以人参、尤为万全之策也。《衷中参西录》中,有很多重用赭石的记载,如一人上焦满闷,难于饮食,胸中觉有物窒塞,用赭石六钱,研末,浓煎人参汤送下,须臾腹中如爆竹之声,胸次胸中俱觉通豁,至此饮食如常。他感叹说:如此良药,今人罕用,间有用者,不过二、三钱,药不胜病,用与不用同也。张锡纯常用生赭石研末数钱吞服,汤剂则每用一、二两以上,效如桴鼓而不伤人。原书俱在,可复按也。

Doctors in the later times generally believed that this formula is used in the clinic condition, in which the person has weakness condition in stomach (digestive system) but with accumulation of phlegm in it, which causes the symptoms. For the weakness condition, Master Zhongjing Zhang used little amount of herb Daizheshi with fear that a large amount of it may hurt stomach Qi further more. This might sound reasonable, however it is not  always matching the clinic practice. There is a saying that the Daizheshi is biter and cold in herbal nature. It may hurt stomach Yang Qi, so that it is used only 3 grams each time. Such believing though comes from book <<Shen Non Ben Cao Jing>>, but there is the bitter taste from the Daizheshi? Dr. Xichun Zhang said in his book <<Zhong Zhong Can Xi Lu>>: “The herbal nature of the the Daizheshi is neutral and calm. It works to dispel Xie Qi without hurting body defense Qi at all”, “in heart Qi deficient condition, the Renshen is also used in the formula to prevent any side effect.” In the book <<Zhong Zhong Can Xi Lu>>, there are many formula that use the Daizheshi. For example, one person felt bloating and fullness in chest, hard to eat anything. He was given Daizheshi 18 grams to grind into powder. The powder was asked to be swallowed with help of drinking strong Renshen Tang for easy swallow. Soon after the drink, he felt very big noise in belly as explosion of a firework, and gradually the chest felt much released loose. From then on, no problem for him to have drink or to eat. Dr. Xichun Zhang signed with feelings and said: “For such good herb ingredient. It is rarely used by doctors in current times. Even if someone did use it occasionally, they used it only for several grams. The herb dose is less while the disease is severe. No different for use it in the formula or not use it at all.

 

4. 风湿三方

4. Three herbal formula for the Wind-wetness disease

 

见《伤寒论》太阳篇174175条: 伤寒八、九日,风湿相搏,身体疼烦,不能自转侧,不呕不渴,脉浮虚而涩者,桂枝附子汤主之。(桂枝四两、附子三枚(炮)、生姜二两、大枣十二枚、炙甘草二两)。

It is stated in the paragraph 174 and 175 in the book <<Shang Han Lun>> : After eight to nine days of Shang Han disease, due to the entangle of the Wind and the Wetness, the body feels annoying pain, hard to turn the body. The person has no nausea or thirsty, and the pulse feels floating, weak, and not smooth. In this case, use Guizhi Fuzi Tang for the treatment. (Guizhi 120 grams, Fuzi 90 grams (processed), fresh ginger 60 grams, Chinese date 12, Zhi Gancao 60 grams.)

风湿病是伤寒病的类证,风湿相搏,似应作风湿相抟,可能是形近之误,风与湿皆为病邪,何以相搏?应作者,合也。风寒湿先后杂至,合而为痹,以至身体疼烦,转侧都困难。甚么是疼烦?即是疼痛剧烈,又表示无休无止。何以只言风湿不及于?寒湿同气故也。所谓风湿实际上是风寒湿合邪。不呕、不渴,是说病与少阳、阳明无涉,还在太阳。浮,表示病邪在表,虚则无力之脉,卫阳不振也;涩,则营卫为湿邪所郁之象,治用桂枝汤为基础,则汗出畏风之证自不待言矣。假若无汗表实,那就是麻黄加术汤证,无用桂枝汤之理了。

The Wind-wetness disease is associated, or can be developed from the Shang Han disease. For the entangle of the Wind, Wetness, and the Cold in the body, the body feels annoying pain, which makes difficult even for the body to turn. What means annoying pain? It means the pain is severe and it is continuous without end. Why it mentions only the Wind and Wetness, but not Cold? It is because the Cold and the Wetness belongs to the same Qi. The so called Wind-wetness actually means the combination of the Wind, the Wetness and the Cold, all of which combine to cause a disease. That “no nausea” and “no thirsty” mean the disease is still in the Taiyang phase, but not in the Shaoyang or Yangming phase yet. “Floating pulse” indicates that the disease Xie Qi is in the body surface phase. The “weak pulse” suggests the defense Yang Qi is weak. The ‘no smooth pulse” indicates that the body Ying and Wei Qi are suppressed by the Wetness Xie Qi. That “to treat, use Guizhi Tang as basic formula” implies that the person has also sweat and dislike wind. If the body is without sweat, it would be the indication to use Mahuang Tang plus Zhu Tang, no reason to use Guizhi Tang.

用桂枝汤,为何要去掉方中的芍药?是因为主要矛盾在卫外之阳不振,芍药酸寒,反而牵肘,故去之,更增桂枝量,再加附子之大辛大热,旨在温经散寒振阳镇痛。附子用至三枚,则至少在30克以上了,此为仲景方用附子之最大量者,殊堪注意。历来用此方尚属对证,而效不佳者,恐怕关键就在附子的用量上。我治风寒湿,附子总在每剂30克以上,只要单味先煮40分钟,即无中毒之虞。曾治沈阳一女性类风湿性脊柱炎患者,连续用药四年,已服附子数十斤之多,疗效不错,也未见蓄积中毒。

When use the Guizhi Tang, why delete the herb Baishao from it? This is because the main problem is the weak of the defense Qi in the body surface. The herb Baishao is sour and cold. It would be conflict to the therapeutic aim to strength and to activate the Wei Qi in the body surface. To increase the amount of Guizhi, and with the addition of Fuzi, that is strong spicy and strong hot, is aimed to warm the meridian, to dispel Cold, the activate the Yang Qi and so to reduce the pain. The Fuzi used is three, which is at least 30 grams. It is worthwhile to notice that this is the largest dose of Fuzi used by Master Zhongjing Zhang in his various formulas. Previously, when this herbal formula is believed to match the person body condition, but it does not work, the reason for the failure might be due to the not sufficient use of the Fuzi in the formula. When I treat the joint pain due to Wind-wetness-cold, the amount of Fuzi is commonly more than 30 gram. Once the Fuzi is precooked in water for more than 40 minutes, there would no worry for possible toxic reaction. I treated a female who came from Shengyang city of China and who suffered from rheumatoid rachitis. She was given the Guizhi Fuzi Tang continuously for four years. She had taken the Fuzi for more than ten pounds. The healing effect is excellent an no any accumulated toxic reaction was observed.

同一条文中,又有白术附子汤证: 若其人大便硬,小便自利者,去桂,加白术汤主之。

In the same paragraph, there is another herbal formula: Baizhu Fuzi Tang: it is used when the person has difficult bowel movement (the stool is hard to pass), and the urine is frequent. In this case, remove Guizhi but add Baizhu in the formula.

从前许多注家和研究者如舒驰远、陆渊雷、程门雪以及我的一位老师,对此条都表示过怀疑,认为当改作大便溏,小便不利。

Previously, there were many scholars and doctors, such as Dr. Chiyuan Shu, Juanxue Lu, Menxue Chen, and one of my teachers, who doubt this statement. They believed that the words should be changed to “the person… is with diarrhea, but difficult in urine.”

我认为:(1)这一段文字,是承接前文来的,也就是说,风湿在表,并且是在用过桂枝去芍加附子之后,卫阳不振,风寒虽去,而湿邪犹留,身体仍痛,不能自转侧。

I believe, however, (1), this statement is following the previous one. That means, the Wind-wetness in the body surface, and the body had been treated with the formula Guizhi without Shao plus Fuzi. The body is with weak defense Yang Qi. The Wind-cold though has been depleted from the body, the Wetness remained, so that the body still feels pain and hard to turn over.

2)大便硬(《金匮要略》作大便坚),小便自利,正是点明湿不在里,不要以为这就无湿了。风去,则无须桂枝之辛散走表;湿留,故有取于白术,术得附子,逐湿之功益著,盖湿为阴邪,非温不解也。何以知术附能逐在表之湿?其方后注云:右五味以水六升,走取二升,去滓,分温三服。初一服,其人身如痹,半日许复服之,三服却尽,其人如冒状,勿怪,此以附子术并行(《金匮》)皮内(《金匮》皮内皮中),逐水气未得除,故使之耳。(《金匮》故使之耳故耳。) 好一个附子、术并行皮内,逐水气(湿)!不是很明白地告诉我们术附同用逐湿于表么?

(2). The “difficult in bowel movement but frequent in urination” just suggests that the Wetness is not in the inside of the body. Do not think that there is no wetness here any more. The Wind has been depleted, so that there is no need to use Guizhi to go to the body surface. The Wetness remains, so that it is needed to use herb Baizhu. The Fuzi is used with the help of Baizhu, its ability to deplete the Wetness is increased. For the Wetness belongs to a Yin Xie, it would not be depleted off without the use of Warming therapy (by use of herbs such as Fuzi). How could we know that the Fuzi plus Baizhu could deplete the Wetness? Here is the text following the paragraph: “Add water six liters into the herbs, cook until there is two liters left. Remove the residue, collect the herbs liquid (extract). Separate it into three parts. Drink one part each time, three times a day. Once drink it the first time, the person feels as pain in whole body. After half day, drink the second part. Another half day, drink the remaining part. If the person feels cloudy as drunken, do not feel any worry. This is because the Fuzi and the Baizhu go together in the skin, and the Wetness has not been completely depleted yet, so to cause more pain. Is this clearly indicating that the use of Fuzi and Baizhu together could deplete the Wetness in the body surface?

3)表有湿而里无湿的情况应该是有的。因为这两条三方一开始点明伤寒八、九日,就可见其病程不长,还在表,在太阳,不是表里同病,不是中外皆湿。

(3). There should be a condition, in which there is Wetness in the surface, but not in the inside, of the body. This is because from beginning of these three formulas here, it has been indicated that it is the eight to nine days of the Shang Han disease. Clearly the history of the disease has not been too long yet. The Xie Qi is in the body surface, in the Taiyang phase. It is not the illness in both the body surface and inside, not the Wetness in both the outside and the inside of the body yet.

4)当然,如果真是表里都有湿,外见身痛不能自转侧,内见大便溏,小便不利,用此方则表里之湿并逐,亦属正治。

(4). Surely, if in deed there is Wetness in both the surface and the inside of the body, the person feels pain in whole body, hard to turn the body over, and has “diarrhea and difficult in urination.” This formula is of course suitable to use, to deplete the Wetness from both the body surface and the inside.

如留聚于关节之寒湿失治,而见骨节疼烦,掣痛不得屈伸,近之则痛剧 (寒主收引,主痛,寒湿相合,更加留连不解),小便不利(湿无出路),身微肿(亦是湿聚),仲景又续出甘草附子汤一方,因为病久 (不止八、九日),而表卫不固,汗出恶风不欲去衣,更加短气 (阳气受伤),诸证合而观之,乃为表里之阳俱虚,风寒湿邪俱胜。甘草附子汤用桂枝附子温振表里之阳,白术、甘草崇土驱湿。唯湿邪之性,黏滞缠绵,不能遽除,故以甘草名方,示人以缓而行之之义。玩味此方用药,是将桂枝去芍加附子汤,桂枝去桂加白术汤二方合为一方去姜枣而成,如果说桂枝去芍加附,偏重于风(),去桂加白术,偏重于湿(),那么此方则表里之阳共振,风寒湿邪并祛之法也。

If the Cold and the Wetness that has been accumulated in the joints and are not depleted, the person would feel annoying pain in the joints. The pain is so severe that the joint is hard to bend. The touch or to strech of the joint would cause very much pain (The cold documinates the contract, the pain. When the Cold is entangled with Wetness, the Wetness would stick in the joint and hard to be depleted). There is difficulty in urination (there is no outlet for the Wetness). The body is slightly swelling (It also indicates the retension of the Wetness in the body). In this case, great master Zhongjing Zhang showed us the Gancao Fuzi Tang. For a longer time of the disease (more than eight to nine days), the body surface defense system is weak, the person has sweat, feels dislike wind (or air conditioning), hates to take off clothes, and feels more short of breath (the Yang Qi has been hurt). Consider all the symptoms together, the disease condition now is the weakness in the Yang Qi in both the body surface and the inside, and the Wind, the Cold, and the the Wetness, all are overwhelming now. In the Gancao Fuzi Tang, the Guizhi and Fuzi are used to warm up the Yang Qi in body the body surface and in the inside. The Baizhu and Gancao are to nourish the Splenn (the Soil) so to deplete Wetness. For the specific characteristics of the Wetness, e.g. the stickness, it is hard to deplete quickly. Therefor, use the Gancao as the name of the herbal formula, is to remind that, this disease condition has to be solved slowly. Analysing this formula, it is developed from the Guizhi without Shaoyao plus Fuzi Tang and the Guizhi without Guizhi plus Baizhu, but deplete the ginger and the Chinese date. If we agree that, the herbal formula Guizhi without Shaoyao but plus Fuzi Tang works more for the Wind and the Cold condition, and the Guizhi without Guizhi but plus Baizhu is more for the Wetness (the Cold), the Gancao Fuzi Tang would work more for activation of the Yang Qi in both the body surface and the inside, as well to deplete all the Wind, the Wetness and the Cold the same time.    

饶有兴致的是《金匮要略》治疗历节病的桂枝芍药知母汤,竟是此三方与麻黄加术汤、乌头汤的一个合方,方用桂枝、麻黄、防风、生姜祛风寒通经络于表,白术祛湿于里,用附子既助麻黄桂防姜祛风寒于表,又助白术祛湿于里,一物两用,相得益彰。至加芍药、知母的意思,多以病久,风寒湿邪郁而化热作释。但风寒湿邪并未完全转化为热,所以只用芍、知兼顾其热。临床我以为应用本方可见多种情况:一、全身怕冷,局部肿痛灼热;二、虽无局部肿痛灼热的症状,但有口燥、咽干;三、甚么局部有热的症状也没有,也无口干,但要长用久用,用知、芍防止热药化燥伤阴。

It is interesting that, the herbal formula Guizhi Shaoyao Zhimu Tang, which is introduced in the book <<Jin Kui Yao Luo>>, for the treatment of Li Jie Bing, is the combination of these three formula here, together with the Mahuang plus Zhu Tang, and Wutou Tang. In the final formula, the herb Zhizhi, Mahuang, Fangfeng and fresh ginger work to dispel Wind and Cold, with the aim to conduc meridian. The Baizhu is to dispel Wetness in the inside of the body; the Fuzi is to help Mahuang, Guizhi, Fangfeng and ginger to dispel Wind and Cold in the surface of the body, and to help Baizhu to dispel Wetness inside. It is good to use a single herb with two functions. The aim to use the Baishao and Zhimu is to dissovel the Hotness that is due to the long term of disease, during which the Wind, the Cold and the Wetness may develop Hotness/Fire in the body. However, the Wind, the Cold and the Wetness are not all completely turned into the Fire yet, so only use the Baishai and Zhimu for a prevention (not use strong other herbs, such as Shigao, Huanglian, or Dahuang). In clinic, I believe that, this formula can be used in various conditions: (1), The whole body feels cold but the diseased local feels pain, swelling, burning hot; (2), there is no sign for local hot, but the person feels dry mouth and throat; (3), there is no sign of local hot, either dry mouth or throat, but the herbal formula has to be used for a longer time, so it is needed to use the Zhimu and Baishao to prevent development of dryness due to long term use of hot herbs.

姜春华老师曾经指出:桂枝芍药知母汤,对风湿性、类风湿性关节炎有卓效。关键在于附子,不用则无效。我在这里还要补充一点自已的体会:附子用量不足亦不效。

It has been pointed out by Teacher Chunhua Jiang that the herbal formula Guizhi Shaoyao Zhimu Tang works well for rheumatoid and rheumatic arthritis. The key point is the use of the herb Fuzi. No Fuzi, no effect. Here I have to point out further more: it would not work either if the dose is the Fuzi is not sufficient.

 

5.  桂枝加附子汤

5. Guizhi plus Fuzi Tang

 

此为太阳病治疗不当引起的变证。太阳之治,本当发汗,仲景善用汗法,但特别谨慎,不说表实证之用麻黄汤了,就是表虚证的桂枝汤,也反复叮咛:要取微似有汗,不可如水流漓,否则病必不除。太阳病,既可能是麻黄证、大青龙汤证过汗,也可能是桂枝证误用麻黄汤而汗漏不止,一字形容汗出不止历历如绘,似比如水流漓更重,盖如水流漓犹有止时,则无休无止之谓,其病机则为卫阳虚不能固密。其人恶风是指阳虚失于温煦,小便难,四肢微急,难以屈伸,既与阳气失养,气化不行有关,也与汗出太多大伤津液不无关系。

The herbal formula Guizhi plus Fuzi Tang is used to solve the clinic condition, which is due to a wrong treatment of Taiyang disease. The correct treatment of the Taiyang disease is to sweat therapy. Master Zhongjing Zhang is good at the use of the sweat therapy. But he is very careful. For body surface overwhelming condition, he uses Mahuang Tang. For a body weakness condition, he however, uses Guizhi Tang. Even in the use of the Guizhi Tang, he repeatedly remind to create a mild sweat, not a strong sweat as water flow, otherwise the disease would not be healed. During the treatment of Taiyang disease, the use of Mahuang Tang and Da Qinglong Tang may cause strong sweat, so to cause additional trouble; the use of Guizhi Tang in a wrong way could also cause a water-flowing sweat (so that the disease would not be healed). The reason is that the body surface is so weak as not being able to seal the sweat hole. The “dislike wind feeling” means that the Yang deficiency that fals to warm up the body surface. The “difficulty in urination, slight spasm in arms and legs, that are hard to stretch” is due to the insufficient nourishment by the Yang Qi, as well as to the loss of body liquid part after heavy sweat.

仲景因此而用桂枝汤加附子,调营卫,固表阳,则汗可止,汗止则津液自复。前人有说此条是误汗而阳气阴津两亡,似乎言之过重,如是亡阳那就要用四逆汤回阳救逆,而非此方所能治的了。

Master Zhongjing Zhang therefore uses the Guizhi Tang plus Fuzi, with the aim to adjust the Ying and Wei Qi, to seal the body surface, so to stop the heavy sweat. The sweat is stopped, so the body liquid part is restored. Previously some people believed that this paragraphy referres to the condition in which the Yang Qi and the Yin Liquid part both is to die off due to heavy sweat. It appears over-stated. If the Yang Qi is really to die off, the Si Ni Tang should to urgently used to save the Yang Qi. The Guizhi plus Fuzi Tang is not sufficient to solve it.

此证多见,患者一旦伤风感冒,便中西药杂投,遂至大汗不止者,比比皆是。转思前人畏麻桂如虎狼,不知今之胡乱用药,更远逾麻桂矣。犹记78年一个夏天,正值抢种抢收季节,一女青年因夜晚加班干活受寒,头痛恶寒发热无汗,医者既注射安乃近针,服APC,再加中药荆防败毒散,冀其速愈,遂至汗漏不止,恶风,盖三床被子,门窗紧闭,犹自呼冷,已近半月矣。我用桂枝附子汤合玉屏风散,调治多日始愈。又,七十年代末,我在北京读书时,岳美中先生的女婿唐老师,患感冒,自用速效感冒胶囊4个,即汗如雨下不止,手足拘挛不能屈伸,恶风,小便难,急召时振声老师往诊,时即用桂枝加附子汤,又输了几瓶盐水才好。

Such clinic condition is pretty common. For example, once a person suffers from a common cold, he would be given both the western medicine and Chinese medicine for the treatment, which causes heavy sweat. This makes me remember that, doctors in old time fear the use of herb Mahuang and Guizhi very much for heavy sweat it may cause. Now, the wrong use of the western medicine is much worse than the use of the Mahuang Tang and Guizhi Tang. I remembered one case. It was in the summer of 1978. It was the season of harvest. A female youth catched cold, due to over-work during the previous night. She felt chilly, fever, and no sweat. Doctor gave her injection of analginum, and oral intake of APC, plus the drink of Chinese herb Jing Fang Bai Du San, with the hope to get better sooner. However, it came to her a very heavy sweat. She felt very chilly, even with three layers of coverings, with the door and windor closed tightly. She felt as such for half month. I gave her the Guizhi Fuzi Tang plus Yu Ping Feng San for several days and eventually she got recovered. Anoter case was in the end of 1970s, when I went to school in Beijing. Teacher Tang, who is the son-in-law of famous doctor Meizhong Yue, suffered from cold. He used by himself four capsules of the Suxiao Ganmao Capsules. Soon he got a heavy sweat as rain. His hands and feet felt spasm and hard to streach out. He felt disliking wind, difficulty in urination. Dr. Zhenshen Shi was urgently asked to come for a consultation. The doctor gave him the Guizhi plus Fuzi Tang, as well as several in vein infusion, before he got better.

 

 

6. 桂枝加厚朴杏子汤

6. Guizhi plus Houpu Xingzi Tang

 

《伤寒论》太阳病上篇,桂枝加厚朴杏子汤证,历来有两种不同的句读,一作:喘家作,桂枝汤加厚朴杏子佳。一作喘家,作桂枝汤,加厚朴杏子佳。前一种读法,是说平日素有喘病,今又发作(作,作发作);后一种读法,是说平日素有喘病者,用桂枝汤 (作,作)。当以后者为是。为甚么要作()桂枝汤?说明必有桂枝汤证如恶风、发热、汗出、脉浮缓也;何以会有桂枝汤证?太阳中风,营卫不调也。此必喘病宿疾,为非时之感引动,所以在处理主证用桂枝汤的同时,更加厚朴、杏仁下气平喘照顾宿恙也。喘家所患的也可能是麻黄汤证,也可能是小青龙汤证,也可能是越婢加半夏汤证,都可以依此原则处理。小青龙汤方后即有 若喘者去麻黄加杏仁半斤(去皮尖),可为例证。

For the Guizhi plus Houpu Xingzi Tang, in the First part of the book <<Shang Han Lun>>, there are, in history, two different ways to read it and to understand it. One way is to read it as “when the asthma comes, the Guizhi plus Houpo Xingzi Tang works well.”  Another way is to read as: for person with asthma (even if the asthma does not break out), use the Guizhi Tang. The addition of the herb Houpo and Xingzi would be better”. We should understand it as the later one. Why the Guizhi Tang should be used? It is because there must be the symptoms of wind-dislike, fever, sweat, and floating-slow pulse. Why there is such Guizhi Tang condition? It is because in the Taiyang Wind-attack phase, the Ying and the Wei Qi is in disorder. This condition must be a long term disease, which is triggered by a external wheather change. Therefore, when the main clinic condition (such as wind-dislike feeling, fever, sweat, etc.) is treated with the Guizhi Tang, the addition of herb Houpo and Xingzi (Xingren, e.g. apricot) to solve the old asthma would prevent the stirring of the old asthma out. For a person with a history of asthma, the current condition might indicate the use of Mahuang Tang, or Xiao Qinglong Tang, or Yuebi plus Banxia Tang. All such conditions can be treated similar the the Guizhi Tang here, e.g. with the addition of Houpo and Xingzi, into the main herbal formula. One of the examples is the statement followed the herbal formula Xiao Qinglong Tang, “if the person has the history of asthma, remove herb Mahuang but add Xingren 125 gram (take off the tips and the skin of the Xingren).  

字,颇觉亲切。佳者,好也。这可以是仲景信笔记下的心得体会,也可以理解为仲景当日博采众方留下的一点痕迹。

The Chinese word “Jia” here makes a kind feeling in heart. The “Jia” here means “Very good”. It might be the experience record by Master Zhongjing Zhang at his time, or it is the evidence that Master Zhongjing Zhang learned from other doctors at his time.

一老人,有喘病史,每年冬天都要因呼吸道感染住一、二次医院。今值隆冬,因开窗透气感寒而病,其证恶风发热,微汗、气喘、脉浮滑、舌淡紫,我用桂枝加厚朴杏子汤后一剂知、二剂已。我学用仲景书的方法是:方证完全相符者,可以径用原方,如本患者是;方证大体相符者,用原方加减;方证不符者,即当另觅处方或独立思考,因用药,不拘于原方。

A old person, who had had history of asthma. He would have to be admitted into hospital once or twice every winter for the respirotary infection. Now it is the deep winter. He had broken out of the disease because he opened the window to have fresh air. He felt wind-dislike feeling, slight sweat, and asthma. His pulse was floating and slippery, and his tongue is slight purple in color. I used Guizhi plus Houpo and Xingzi Tang to him. The first dose made him feel better and the second dose cleared all of his symptoms. When I learn the herbal therapy from Master Zhongjing Zhang, my way is: if the body condition completely matches the indication to the herbal formula, use the exact herbal formula without any modification, such as in this case. If the body condition is roughly matching the indication of the herbal formula, modify the formula some how. If the body condition does not match any herbal formula in the book <<Shang Han Lun>>, try some other herbs in other books, or try to set up a new formula by my own. To use the herbal formula bases on the body specific condition, not stick the the original formula.   

 

7. 关于理中汤的两种加味

7. The two modifications for formula Li Zhong Tang

仲景原文并没有把理中汤、丸作为太阴病主方。理中丸见于《伤寒论》辨霍乱病脉证并治篇。太阴病以吐、利、腹痛、腹满为特征,属太阴脾虚寒证,仲景提示治法是当温之宜服四逆辈。理中丸由人参、白术、干姜、炙甘草组成,当属四逆辈。理中丸及汤的加减法中,本有腹满(阳虚寒凝),去术加附子一枚,寒者加干姜,足证其当属四逆辈。正是由于如此,后世才移用此方作为太阴病主方。

In the original text, Master Zhongjing Zhang did not list the Li Zhong Tang as the main herbal formula for the treatment of Taiyin Bing. The Li Zhong Tang is seen in the Chapter of Cholera in the book <<Shang Han Lun>>. The characteristic of the Taiyin disease is the vomit, diarrhea, stomach pain, and stomach fullness. It belongs to the Taiyin weakness-Cold condition. Maste Zhongjing Zhang reminded that the treatment principle is the “warming therapy”, and that the herbal formula should be the Si Ni group. Li Zhong Wan is consist of Renshen, Baizhu, dried ginger, and Zhi Gancao. It should belong to the “Si Ni” group. In the introduction for the modification of the Si Ni Wan and Si Ni Tang, it has been indicated that, if the person has bloating in the belly (indicating the Yang deficiency and Cold stickness), remove the Baizhu but add one Fuzi (about 30 grams), and if the person has cold condition, add dried ginger. Clearly, it belongs to the “Si Ni” group. For this reason, later doctors used it as the main formula to the Taiyin disease. 

理中汤的加味方很多,在我用理中汤的经验中,有一热一寒的两味药的加入最为重要。

There are many ways to modify the Li Zhong Tang. In my experience, the most important modification is one hot herb addition and one cold herb addition.

 

(1). 理中汤加附子

(1). Li Zhong Tang plus Fuzi

这就是理中汤与四逆汤的合方。加附子是为了振奋脾肾之阳,是虚寒之象的进一步发展,也可以是太阴传少阴,太阴少阴同病。其证除吐、利、痛、胀外,尚见手足逆冷。

This is the combination of the Li Zhong Tang and the Si Ni Tang. To add Fuzi is to activate the Yang Qi in the Spleen and the Kidney. Such condition might be the result of further development of the weakness-Cold condition, or of the pass of the Taiyin phase to the Shaoyin phase, so the Taiyin and the Shaoyin phase exist in the body same time. The body condition should show as cold hands and feet, beside the vomit, diarrhea, pain and bloating.

周某,女,8个月。体质弱。先因伤食,医用消导不应,改硝黄下剂,即腹泻不止,后来改用西药,不意服硅碳银、活性炭后,药亦随大便排出,泻出物皆稀水,日十余次,精神萎顿,头额冷汗,肢厥,舌淡。补液后腹胀。病在太阴,脾阳衰败,累及少阴,虚寒证也,用理中汤加附子、灶心黄土,一帖泻止,易以异功散调理数日而安。

A girl, 8 months old. She was very weak in body constitution. For improper diet, she suffered from indigestive symptoms. Doctor gave her some medicine to help the digestion but no effect. She was then given Puxiao and Dahuang for colon cleansing therapy. Soon she had continuous diarrhea. She was then given western medicine, but after intake of silicon carbon silver and active carbon, these medicine past into the stool too. The diarrhea was all the water, tens times a day. Her spirit was very low, with cold sweat in head, cold in hands and feet. The tongue was much less red in color. After in vein infusion, she got stomach bloating. The disease was in the Taiyin phase. The Spleen Yang Qi was very weak, which affected the Shaoyin phase too. All the body conditions belong to Weakness-Cold condition. She was given Li Zhong Tang plus Fuzi, Zaoxin Huangtu. One dose made the diarrhea stopped. The herbal formula was changed to Yi Gong San for several days. There was no any symptoms after that.

左某,男,64岁。初春某日,晨起放牛上山,归家即呕吐、腹泻、肢厥,昏睡不起,察其舌淡苔白,脉沉细。初议用四逆加人参汤(红人参10克,附子24克,干姜15克,炙甘草6克),后采纳会诊医生意见再加白术、龙牡,浓煎以进,一服即酣然入睡,尽剂而安。

 Patient Zuo, male, 64 years of old. One day in a early spring, he went to mountain to graze cattle. After he went home, he had vomit, diarrhea, cold hand and feet, loss consciousness. His tongue was less normal red, and the tongue cover was white. The pulse was deep and thin. Initially, he was to give Si Ni Tang plus Renshen (Red Renshen 10 g, Fuzi 24 g, dried ginger 15 g, and zhi Gancao 6 g). Later other doctor’s idea was taken, to add more Baizhu, Longgu and Muli in the formula. The herbs were cooked. One drink of the herbal tea helped him to fall into sleep. After finish the whole herbal tea, he got completely recovered.

周某本脾虚不足之体,由误下而致太阴虚寒,累及少阴。所服活性碳亦随之泻出,中阳不振也;补液更增腹胀,中虚失运也,此际若至用理中汤,犹嫌药力不足,必得附子之大力,姜附协力,始可回阳救逆,挽回败局。左案则为寒邪直中太阴、累及少阴,非四逆辈不可为功。

In the first case, Mr. Zhou was in Spleen deficiency for a long time. Due to mis-use of a colon cleansing therapy, he got the weakness-cold condition in Taiyin phase, which was also affecting the Shaoyin phase. The active carbon that he took was also past in the stool, indicating that his middle Yang Qi is insufficient. The in vein infusion caused his bloating in belly, suggesting that the middle Spleen system failed in transportation function. At this time, if the Li Zhong Tang was used, there was worry that the ability of the herbal formula was not so strong enough to solve the problem. The addition of Fuzi to enhancse the herbal formula, and that of the co-work by the Fuzi and dried ginger to help the herbal formula, needed to be considered, so as to reach the goal to save the Yang Qi in the body. In the second case, the Cold Xie Qi penetrated directly into the Taiyin and Shaoyin phase. The Si Ni Tang, and similar formulas, must be used to save the life.

 

(2).  理中汤加黄连

(2). Li Zhong Tang plus Huanglian

方出丹溪《证固脉治》。张潞说本方主治胃虚挟食,痞满发热,戴复庵说盛暑逼于外,阴冷伏其中,俱难得其要领。我的理解,无非脾胃虚寒而又挟肠热,多年来用此方治疗泄泻屡收捷效。

The formula Li Zhong Tang plus Huanglian comes in the book <<Zhen Gu Mai Zhi>>. Dr. Lu Zhang said this formula works mostly for “Stomach weakness with non-digested food accumulation. The person felt bloating and fever”. Dr. Fu-an Dai said it works for a condition, in which “the very hot summer Qi is dispelled in the body surface, and the Yin Cold Qi hides inside of the body.” Both statements do not catch the real meaning of the herbal formula indication. To my understanding, it works just for the Spleen-Stomach weakness and cold with the accumulation of intestine hotness. For many years, I used this formula for the treatment of chronic diarrhea. It worked many times.

黄某、女、76岁,久患糖尿病,最近突发不明原因的泄泻,日四、五次,在某医院治疗半月不效,腹部隐痛,时胀,食不下,口不渴,察其舌质色淡而苔黄腻,断为中寒而挟肠热,用连理汤三剂而愈。

Patient Huang, female, 76 years of old. She suffered from diabetes for many years. Recently, she got diarrhea with unknown reason, which was four to five times a day. She had been treated in a hospital for half month without improvement. She had mild pain in the belly, with bloating feeling from time to time. She had no appetite, no thirsty. Her tongue is less red than normal. The tongue cover was yellow and greasy. Her condition was diagnosed as middle Cold with intestine hotness. She was given the Lian Li Tang three doses only before she got better completely.

谢某、女、56天,腹泻52天,体重不增,某医院用过消导健脾药多付不效。精神萎靡,面色苍白,皮肤干皱,啼哭不宁,而肛门红灼,遂用连理汤,二剂泻即止,易方调理而愈。

Patient Xue, female, 56 days of old. She had diarrhea for 52 days. Her body was not increased. She was treated in a hospital with the use of digestive medicine for many doses without improvement. She was very low in spirit. She had pale face, shriveling skin. She cried continuously. She had red and hot around the anus. She was given the Lian Li Tang for two doses. The diarrhea stopped. Other herbal formula was given later for a maintenance treatment.

 

8. 小陷胸汤

8. Small Xiexiong Tang

 

小陷汤方 (黄连6克、半夏9克、全瓜蒌30),见《伤寒论》太阳病篇138条。

The Small Xiexiong Tang (Huanglian 6 g, Banxia 9 g, Whole Gualu 30 g) is introduced in the paragraph 138, in the Taiyang phase of Shang Han disease, in the book <<Shang Han Lun>>.

小陷胸汤,原文颇简略:小结胸病,正在心下,按之则痛,脉浮滑者,小陷胸汤主之。心下,言其病位;浮滑脉主痰热,言其性质。按之痛,则痰热结滞,陷于胸脘,气机不得升降宣通之故。

For the Small Xiexiong Tang, the original statement for the indication to use it is: “the Small Jiexiong disease is just under the heart. It would be pain with press. The pulse is floating and slippery. Use Small Xiexiong Tang as the main formula to treat it.” The “under the heart” indicates the location of the disease. The floating and greasy pulse suggests the phlegm and hotness, indicating the nature of the disease. Pain upon press indicates the entangles of the phlegm and the hotness, which sticks in the chest and stomach region and blocks the circulation of the Qi there.

考《伤寒论》、《金匮》二书中,均无字,《内经》亦然,然则仲景时代,岂无痰热之病乎?有之,此方即典型的痰热方。半夏,痰饮之常用药,体滑性降,而不免于辛温,合黄连、瓜蒌,则辛以开结,寒以泄热,能通能降,药虽寥寥三味,却至精至当,后世方几无与匹敌者也。

Check the book <<Shang Han Lun>> and <<Jin Kui Yao Luo>> for the corresponding paragraphs, there is no word “phlegm”, so did not in the book <Huang Di Nei Jing>>. However, it would be strange if there was no Phlegm-hotness in the time of Master Zhongjing Zhang. If yes, there is, it is this formula that works for such condition. The herb Banxia is the commonly used  ingredient to dispel phlegm. It is slippery and descending in herbal nature but tends to be spicy and warm, which may cause unexpected side effect. With the use of Huanglian and Gualu, the spicy works to open and to disperse; the cold (from the Huanglian and Gualu) works to dispel Hotness. The whole formula can function to both conduct, to open and to cause descending effect. Though the formula is consisted of only three ingredients, it works very well, and it is hardly replaced by any other formula developed in later times.

小陷胸汤证多见于:慢性支气管炎急性发作、肺炎、胸膜炎、胃炎、黄疸肝炎等疾病过程中,凡表已解,痰热阻滞,病在胸脘(呼吸系、消化系),证见:1.脉浮滑而数;2.舌质红、舌苔黄腻;3.咳喘而咯痰黄稠胶黏;4.黄疸;5.便秘;6.胃部痞满;7.胸膈或胃部按之则痛者皆有卓效。我很惊讶,仲景的观察竟如此细致!记得几年前我为一87岁老人重症肺炎会诊,病已一周,病情日重,已上呼吸机。我按他的胸膈部及胃部,他虽不能讲话,神色却立见痛苦之状,投以小陷胸汤,立见转机。

The clinic conditions that need the use of the Small Xianxiong Tang are commonly seen in: the acute break out of chronic bronchitis, pneumonia,  pleurisy, gastrotitis, jaundice hepatitis,etc. The body surface syndrome has been solved or no longer exist, but there is phlegm and hotness block in the chest and stomach region. In clinic, the patient would have: (1), floating, slippery and frequent pulse; (2), stronger red color in tongue; yellow and greasy tongue cover; (3), cough and asthma with yellow, sticky and thicker phlegm; (4), jaundice; (5), constipation; (6), bloating feeling in stomach region; (7), pain upon press on the chest or stomach region. I am very surprised that Master Zhongjing Zhang was so careful in the clinic observation! I recalled one old man, who was 87 years of old. He was sick for one week, which was worse and worse and he had to use automatic respirotary machine. I pressed his chest and stomach. Though he could not speak, his face showed painful expression right away. I used the Small Xianxiong Tang to him. His condition was very soon improved.

小陷胸汤证,多见于伤寒在表误下而致者。需要提醒: 误下,不要片面理解为是用芒硝、大黄,大凡表未解者,苦寒之剂在某种意义上皆与攻下剂相同,表邪内陷而冰伏,邪热熏灼津液为痰,而酿成痰热结于胸脘之候。当然,也有痰热久蕴,为外邪引动,或热邪直接由表入里炼津为痰者,未必都是表证误下所致。

The indication to the use of the Small Xianxiong Tang is usually seen when the colon cleansing therapy is mis-used when the disease is still in the body surface phase (e.g. in the Taiyang phase). Here it should be remined: the “mis-use of colon-cleansing therapy” should not be simply understood as by the use of herbs, such as Mangxiao, or Dahuang. Whenever a Cold herb is used when the body surface syndrome (e.g. the Taiyang phase) is present, it would function similar to the use of a colon-cleansing therapy to bring the external Xie Qi be internalized deeper in the body (as hidden ice condition). The internalized Xie hotness burns the liquid part of the body to form phlegm and to cause the entangle of the phlegm and the Hotness in the chest and in the stomach region. Of course, there could also be another way to form such similar clinic condition. For example, when the original phlegm and Hotness are accumulated in the body for a long time (due to some other pathological reasons), which was triggered out by a external Xie Qi attack, or a Hotness Xie Qi penetrates into the body directly and straightly deeper to burn the body liquid part into phlegm. Not means that the entangle of the phlegm and Hotness always is due to an improper treatment.   

小陷胸汤在《外感温热篇》中,叶天士称作苦泄法苦辛开泄。用于温邪传入气分,痰热互结,黏滞难解。叶氏强调小陷胸证必验之于舌,而典型的小陷汤舌象便是他说的舌黄”“或黄或。王孟英则强调此证真伪,必察胸脘,如按之痛或拒按,舌红、苔黄厚腻,脉滑数者,必先开泄,即可用小陷胸汤。都是对仲景叙证的重要补充,盖仲景书独详于脉而略于舌诊也。

In the book << Wai Gan Wen Re Pian>>, the Small Xianxiong Tang was called “bitter-to-dispel therapy”, or “bitter- and spicy-to-disperse therapy” by Dr. Tianshi Ye. It is used when the Wen Xie Qi passes into the Qi phase, the phlegm and the Hotness entangle together and become sticky and hard to be separated. Dr. Ye emphasized that it is very important to check the tongue to find the indication to use the Small Xianxiong Tang. The typical tongue for the indication of Small Xianxiong Tang is what he said the “yellow tongue”, or “or yellow or muddy”. Dr. Menying Wang however emphasized to identify the true or the false of the yellow tongue. He said the doctor must “press on the chest”. If the patient feels pain or refuses to press, and if he has red tongue, yellow, thick and greasy tongue cover, and if his pulse is slippery and frequent, his condition indicates the use of the Small Xianxiong Tang. These statements are all very good complementary supplication to the description by Master Zhongjing Zhang, since Master Zhongjing Zhang’s statement is in detail in the diagnosis by the pulse but less so by the tongue.



[1] Liang: one Liang (old Chinese weight unit) is equal to 15.625 grams.

[2] According to the text above, here should be red as “and if he has no diarrhea, use the Xuanfu Daizheshi Tang for the treatment.” If there is diarrhea, use the previous Shengjiang Xiexin Tang.”